American Board of Ophthalmology Emeritus Director Philip L. Custer, M.D., recently worked with colleagues at Washington University School of Medicine in St. Louis to co-author a piece for July's EyeNet about a memorable patient safety encounter. Edited by ABO Director Jane Bailey, M.D., Dr. Custer’s article tells the story of a patient who underwent wrong fluorescein angiogram. Dr. Custer reviewed the series of events that led to the error and discussed the practice’s response to the mistake. The article is part of a new ABO-led series for the Morning Rounds section of the magazine.
If you have a story you think would help illustrate the importance of patient safety protocols, the ABO is presently collecting anonymized cases. Each story of 1500 words or fewer adheres to a template that includes the following elements:
Brief case description with key details, including:
Explanation of the harm done
Measurements of how much harm was caused
How the harm affected the patient’s life
Root cause analysis
What systemic, cultural, or other factors may have played a role?
What went right? What further harm could have happened if not for positive conditions?
Patient Safety Principles
What could/should have been done differently to improve patient safety?
Several practical solutions
What clinical guides, care processes, resources, references might be useful in addressing the root case?
One piece of art is needed to accompany the article. This could be diagnostic readouts, OCT images, photos, etc. We will redact all patient info. Photos would be cropped so the patient is unrecognizable or the submitting MD must state in writing that he/she has written permission from the patient.
If you are interested in sharing a story or would like to suggest a topic, please write to email@example.com.