Contributors:
Lucian Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health
Kathy Duncan, RN, 5 Million Lives Campaign Faculty, Institute for Healthcare Improvement
Michael Leonard, MD, Physician Leader for Patient Safety, Kaiser Permanente
What is one error that you've made? What did you learn from it? What can others learn from it?
A patient suffers horrible burns. An operation takes twice as long as it should. A child dies from internal bleeding. All because a doctor, a nurse, or another care provider made a mistake. In this video, prominent clinicians describe the errors that still haunt them today — and point out ways those errors could have been prevented.
Learning Objectives
After watching this video, students will be able to:
- Give examples of mistakes that prominent clinicians have made in their patients’ care.
Discussion Group Questions
- What is an error you (or someone you know) made in a health care setting? What did you learn from it? How might it have been prevented?
- Lucian Leape’s story centers around a decision that was based on unambiguous findings in the medical literature. Was his error truly an error, then? Why or why not?
- Kathy Duncan says competent care providers often get flustered during emergencies and don’t take basic safety measures. Imagine you’re the CEO of the hospital where Duncan’s error (burning a patient with an unpadded defibrillator) occurred. What might you do to ensure no one in your hospital would ever make this mistake again?
