Contributors:
Allan Frankel, MD, Director of Patient Safety, Partners Healthcare
Kevin Knoblock, Student, MSN/Nurse Practitioner Program, MGH Institute of Health Professions
Donald Berwick, MD, MPP, President and CEO, Institute for Healthcare Improvement
What is one error that you've made? What did you learn from it? What can others learn from it?
A baby falls gravely ill after a botched blood transfusion. A student nearly commits a medication error. A patient dies after a clumsy surgery. In this video, current and former clinicians (including IHI’s CEO Don Berwick) 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?
- Imagine you’re in charge of the hospital where Kevin Knoblock works. What will you do to ensure no one misreads medication instructions the way he did? How much should you rely on your staff members’ personal efforts to try harder?
- Don Berwick says he felt too guilty to discuss his mistake with his colleagues and the hospital’s managers. If you made a serious mistake that affected a patient, what circumstances would make it easier for you to admit it openly? What circumstances would make it harder?
