Our residents Christina Yek and Arjun Gupta published an article in JAMA this week, with an accompanying podcast! They highlight an incident of iatrogenic phenytoin toxicity at Parkland where an intubated patient received 3X the intended amount of phenytoin resulting in somnolence and delayed extubation.
The article describes how resident-initiated incident reporting sparked a root cause analysis, leading to process improvement and the implementation of systems-based solutions to prevent future recurrences.
We encourage our residents to keep up the good work reporting safety incidents in the work place! Every time you report an adverse event/ safety post, it creates opportunities for quality improvement. Recognizing areas to improve is the first step to improve.
Please save this google form to your phone, and report report report.