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In this case report, the authors present an adverse event possibly caused by miscommunication among three separate medical teams at their hospital. The authors then discuss the hospital's root cause analysis and its proposed solutions, focusing on the subsequent hospital-wide implementation of an automated electronic reminder for abnormal laboratory values that may have helped to prevent similar medical errors.

Introduction Understanding patient safety events and causative factors is an important step in reducing preventable adverse events. The University of Michigan's Graduate Medical Education (GME) Office, Department of Risk Management (DRM), and Office of Clinical Affairs (OCA) collaborated to incorporate a video workshop as a formal introduction to patient safety during orientation for new residents and fellows. This workshop reinforced the importance of effective communication and supervision in patient safety. Methods DRM and OCA produced a video depicting an actual, unanticipated outcome that resulted from a constellation of preventable circumstances, which allows the audience to observe communication and supervision issues that lead to a patient death. The video is followed by a discussion of the patient safety issues seen, why they occurred, and strategies for improvement. Trainee perceptions of the value of the experience were surveyed and collected using a qualitative survey. Results Most responders found the video workshop helpful. Trainees perceived the video and facilitated discussion as an effective way to identify patient safety issues, available resources, and the culture of patient safety at the institution. Conclusion Trainee comments supported the video workshop as an effective way to highlight the importance of communication and supervision in relation to patient safety. In the future, the DRM, OCA, and GME hope to reinforce this shared vision of patient safety through combined educational efforts.