ABSTRACT
It was no one's fault, but it was everyone's fault. The 53-year-old woman had presented with pneumococcal sepsis with disseminated intravascular coagulation and had barely survived but had lost multiple digits. Ten years earlier, she had undergone splenectomy after a motor vehicle accident. There was no evidence that she had received pneumococcal vaccination at any time since the operation. After she recovered, she filed suit against her primary care physician, a doctor in our integrated delivery system. We settled the case and began the work of trying to prevent similar omissions in the future. We discovered that although information technology offers apparently simple tools for solving such problems in care delivery and improving quality and patient safety, it can be surprisingly complex to redesign systems and processes of care-including their human components-to prevent common errors.
