Contributors:

Donald Berwick, MD, MPP, President and CEO, Institute for Healthcare Improvement

Linda Kenney went into the hospital for an ankle replacement. She came out with a host of complications resulting from a mistake that no one was willing to admit. Until Rick Van Pelt, her anesthesiologist, stepped forward.

In Part Three of this case study, you’ll watch Kathy Duncan, RN, and Don Berwick, MD, analyze the case. What went wrong? What should have happened instead? What can we learn from the experience of Kenney and Van Pelt?

Learning Objectives

After watching this video case study, students will be able to:

• Identify constructive approaches to responding to errors in a health care setting.
• Describe the impact of mistakes on patients and on clinicians.

Discussion Group Questions

1. Don Berwick says that both the patient and the provider in this case were victims. How might Rick Van Pelt be considered a victim? What are the implications of that idea for a hospital that’s trying to respond appropriately to an error?
2. Kathy Duncan says that when you’re meeting with a patient who’s suffered from an error, you should sit down and avoid bringing a group of administrators along. What are other steps you might take to avoid intimidating the patient?
3. Kathy Duncan identifies several important steps in the disclosure of an error: being truthful, apologizing, and promising to investigate so the error doesn’t happen again. What are other steps that providers and/or hospitals can take to help all the parties involved in an error?