On Call: What Is It Like to Be Trapped in an Error?
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June 16, 2008
Donald Berwick, MD, MPP, FRCP
President and CEO, Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
Student Moderators: Alexi Nazem, Medical Student, Yale University
Meghan McCann, Nursing Student, University of North Carolina
“I then realized that I had infused almost the entire bag of heparin … I thought that I was probably going to throw up.”
Even the most competent people make mistakes. That’s human nature. But many hospitals don’t design their systems to account for human error, treating mistakes — and the people who commit them — as if they’re individual failures.
In the first conference call sponsored by the IHI Open School for Health Professions, IHI CEO Don Berwick and nursing student Meghan McCann confess awful mistakes they made early in their careers. A system that assumes humans are fallible, they say, is a system that can prevent tragic errors.
Read the transcript
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