Contents

#### **Preface XI**


Thomas B. Zanders and Stanislaw P. Stawicki

Chapter 8 **Transfusion Error in the Gynecology Patient: A Case Review with Analysis 125**

Carly Madison Hornis, R.S. Vigh, J.F. Zabo and E.L. Dierking

Chapter 9 **Patient Safety Issues in Pathology: From Mislabeled Specimens to Interpretation Errors 141** Derek Tang, Peter A. Dowbeus, Michael S. Firstenberg and Thomas J. Papadimos

Preface

Modern healthcare continues to evolve. With the shift away from primarily quantitative meas‐ ures of performance, the new landscape of quality and value-based metrics became the hall‐ mark of the ongoing paradigm shift. *The Vignettes in Patient Safety* book series is an attempt to highlight some of the prevailing healthcare trends, focusing on highlighting the increasingly complex matrix of multidisciplinary teams, rapidly evolving treatments, technological ad‐ vancements, regulatory requirements, and ever greater patient (consumer) expectations.

The third volume of *The Vignettes* is the most successful tome in the current series. This is both a testament to the importance of the topic and a reflection of the high quality of work published in the earlier volumes. The favorable response of our readership also corroborates the growing importance of patient safety as an essential component of the modern health‐ care landscape. In fact, the permanency of the "quality and safety" mindset is slowly becom‐

Despite many important advances in our collective understanding of patient safety, a tre‐ mendous amount of work remains before the ultimate goal of "zero incidence" is achieved across the entire spectrum of the so-called "never events" that continue to affect our health‐ care systems. Topics discussed in the current book include fundamental principles of the performance improvement process, the application of levels of scientific evidence in clinical‐ ly relevant contexts, assessment of patient safety culture in a primary care setting, patient

It is our goal as editors of *The Vignettes in Patient Safety* to introduce new concepts and clini‐ cal scenarios that will enrich the cumulative value of the entire book series. Volume 3 fol‐ lows this important principle as well, adding important information regarding teamwork and communication, the "Swiss cheese" model of medical error genesis, transfusion-related patient safety issues, errors involving pathology labeling and reporting, operating room

The editors of *Vignettes in Patient Safety* would like to thank all of the individuals involved in bringing this important work to fruition. We also want to thank our friends and family who supported our efforts for their patience and understanding during the entire process of book preparation, editing, and readying the content for publication. In addition, we formally ac‐ knowledge and express our appreciation to all of the authors that have committed their val‐ uable time and effort to making this third tome of *The Vignettes* a success. Their contributions, especially in the context of an open source publication model in which the authors support the expenses of a publication, clearly reflect their dedication to the primary objectives of this text—and the passion to share and promote this work's important mes‐ sage. Finally, we must recognize the important role of various departments and institutions

ing the long-sought reality throughout our clinics, hospitals, and operating rooms.

safety education, and a number of different patient safety scenarios.

fires, and various dangers associated with intrahospital patient transfers.

Chapter 10 **Avoiding Fire in the Operating Suite: An Intersection of Prevention and Common Sense 161** Maryam Saeed, Mamta Swaroop, Franz S. Yanagawa, Anita Buono and Stanislaw P. Stawicki
