Why Do Errors Happen? How Can We Prevent Them?

Lucian Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health
 
 
 
 
Learning Objectives: After viewing this video, students will be able to:
  • List at least two examples of common preventable errors that occur in health care.
  • Give at least one example of a health care scenario in which systems thinking could make patients safer.
  • Discuss how system’s thinking can help a clinician deal with the guilt of making a mistake.
Description: Millions of people suffer every year from mistakes in health care.  Lucian Leape, MD, explains why those mistakes happen — and how to prevent them. 
 
Discussion Questions:
  1. Dr. 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?
  1. Can you think of a time when, 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?
  2. 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?
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