Quality Grand Rounds
"Quality Grand Rounds" is a series of 8 articles and companion conferences in a format similar to that of clinical problem-solving cases. Each article describes an actual case involving a medical error or quality issue but does not identify the patient, providers, or institution. Cases do not come from the institutions of the authors or discussants. Although much of the case material is clinical (that is, drawn from the medical record), in a few cases, the involved institutions allowed us (the series editors) to observe their internal fact-finding and problem-solving process, known as "root-cause analysis." In addition, we often interviewed key participants (including the patient, doctor, nurse, or risk manager) to be sure we could convey a full understanding of the events. Parts of these interviews are included in several of the case presentations in the Annals, and additional information can be found accompanying the on-line version of the articles. Each case was presented to the discussants in a conference format (Quality Grand Rounds), and the manuscripts were revised to reflect the issues raised at the conferencesincluding those discussed during the question-and-answer sessions.