Contents

#### **Preface IX**



#### Chapter 4 **Dangers of Polypharmacy 47** Pamela L. Valenza, Thomas C. McGinley, James Feldman, Pritiben Patel, Kristine Cornejo, Najmus Liang, Roopa Anmolsingh and Noble McNaughton


Chapter 8 **Pressure Injury in the ICU: Major Reconstructive Surgery Required 109** Ashley Jordan

#### Chapter 9 **Wrong Blood Type: Transfusion Reaction 149** Holly Ringhauser and James Cipolla

Chapter 10 **Patient Self-Harm in the Emergency Department: An Evidence-Based Approach 157** Ronya Silmi, Joshua Luster, Jacqueline Seoane, Stanislaw P. Stawicki, Thomas J. Papadimos, Farhad Sholevar and Christine Marchionni

Preface

outcomes of our patients around the world.

and thoughts on these complex topics.

we all do better for our patients."

Since the late 1990s, a truly global movement to improve patient safety has evolved into the modern paradigm where safety and quality of care are enmeshed with virtually every as‐ pect of healthcare. This would not be possible without the early pioneers of patient safety, whose vision has evolved into a truly global movement that is helping to improve lives and

This work was conceived because of the continued need for a practical, easy-to-use, and at the same time comprehensive reference in the area of patient safety. The goal of this book cycle is to introduce the reader to key concepts in patient safety while providing clinically relevant context to each case vignette. Although there may be some conceptual overlap be‐ tween different chapters and volumes of the *Vignettes in Patient Safety*, this is done intention‐ ally to help reinforce the most critical concepts and patient safety processes while also allowing for different authors and teams to present their unique perspectives, experiences,

By embracing the case-based, practical approach to patient safety scenarios, we hope to sup‐ port the next phase of growth and development of the global healthcare quality and safety movement. Within this paradigm, the intent is to build on the foundations of the past two decades, to incorporate new evidence-based data, and to synthesize new knowledge that will rejuvenate the cycle of continuous healthcare self-improvement and further enmesh‐ ment of quality and safety into everyday practice of medicine. Moreover, by presenting cas‐ es, the authors can better convey to the readers that while such events are common in healthcare, many occurrences can be prevented using system-based approaches to solutions rather than accepting a defeatist perspective that adverse patient outcomes are inherently unavoidable. In essence, healthcare providers—at all levels—must continue to think beyond the events that occurred during their "shift work" to recognize that they are part of a larger continuum of care and that the fundamental guiding statement should always be "how can

The editors would like to acknowledge the contribution and hard work of all the people who made this work possible. First and foremost, we thank our families and friends, with‐ out whom the time and effort required to complete this book cycle would simply not be feasible. Second, we would like to express our gratitude to all chapter contributors. Their effort is greatly appreciated, and we are confident that this work will help improve both safety and quality of care for patients around the world. Finally, we would like to acknowl‐ edge the generosity of all the departments and institutions for the support of contributing
