Using legal cases to make patients safer

Bouncebacks! Pediatrics encompasses 28 cases of children who were seen in the emergency department, discharged, and then bounced back with a different diagnosis, sometimes reversible, sometimes life-ending.

In keeping with the Bouncebacks! tradition, all include the physician s actual documentation. Next is a discussion of the risk management/patient safety features of the initial encounter, either told by the book authors, chapter author, or in the colorful manner of Greg Henry, past president of the American College of Emergency Physicians (ACEP) and arguably the foremost physician medical-legal authority in the country, having been an expert in over 2,400 medical legal cases. After the condensed description of the return visit (or visits!), the chapter author provides a referenced discussion of the presentation and final diagnosis, all within the context of the case.
The chapters are written by authors who actually cared for these patients, creating a familiarity with the initial presentation and/or bounceback. Commentary often includes a very personal discussion of their initial discovery of the bounceback, and how an adverse outcome affected them personally; sometimes to the point of marital discord and consideration of suicide. What feelings should we have upon recognizing a child we cared for 24 hours ago is being rushed back to the trauma bay or learning that a parent we spoke with only hours ago will no longer be woken on Christmas morning by their 5 year old?

 

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