Contributor:

Lucian Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health

Millions of people suffer every year from mistakes in health care.  Lucian Leape explains why those mistakes happen — and how to prevent them.

Learning Objectives

After viewing this video, students will be able to:

• Summarize at least one reason for employing systems thinking when a mistake occurs in a patient’s care. 
• Give examples of health care scenarios in which systems thinking could make patients safer.

Discussion Group Questions

1. Lucian Leape says “every mistake is due to a systems failure.” Think about your own experiences as a clinician or patient. Have you ever spotted an error waiting to happen? If so, what could have been done to make the system safer?
2. Tell us about a time that, despite your best intentions, you made a mistake that affected someone else. (Examples can come from a health care setting or elsewhere.) What systems or processes could have kept you from making that mistake?
3. What are the main obstacles preventing hospitals from learning from one another’s mistakes? Are the barriers primarily cultural? Legal? Technological? How would you design an ideal system to keep identical, fatal errors from happening in different places?

Discuss this interview with your peers.