editOrials
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IMAJ • VOL
11
• JULy
2009
to err is Human – But to err repeatedly is….????
Shimon Glick MD
Moshe Prywes Center for Medical Education and Immanuel Jakobovits Center for Jewish Medical Ethics, Ben-Gurion University of the Negev, Beer Sheva, Israel
by what they consider preventable ill-
nesses or complications [5].
In spite of the decade that has passed
since the publication of the Institute of
Medicine report there is the general
feeling that too little has changed from
the point of view of reducing the num-
ber of preventable deaths [6].
The natural, and virtually instinc-
tive, reaction of many administrators,
legislators and the media is to identify
the individual who was "responsible"
for an error and punish him/her in one
way or another. Disciplinary actions and
malpractice suits are examples of this
approach. Unfortunately, there is little
evidence that such steps have any signif-
icant impact on the overall incidence of
medical errors. The title of the Institute
of Medicine report clearly reflects its
position that the focus should not be
on the erring individual, who is usually
a competent and careful individual, but
rather on the second half of the title –
"building a safer health system."
Another appealing and relatively sim-
ple reaction to an error is the creation of
an administrative guideline intended to
remedy the perceived problem. Phys-
icians faced with a growing array of
guidelines and instructions, and already
drowning in a flood of paperwork, only
occasionally change their daily habits as
a result of a new administrative edict. A
recent journal article [7], accompanied
by a photograph of the pile of guidelines
received by a British physician over a
short time period, appropriately labeled
the collection "Tower of Babel."
It has become clear that creating that
safer health system is a complicated
multidisciplinary task that requires a
radical cultural change. A consortium
of leaders in the patient safety field [8]
the U.S. Institute of Medicine report
[1], a decade ago, on the frequency
of preventable deaths in the American
health care system sent shock waves
throughout society. Many experts in
the field believe that the scandalous
figures represent an underestimate of
the magnitude of the problem. In Israel,
Donchin [2] courageously examined
prospectively the frequency of poten-
tially fatal errors in his own intensive
care unit, finding an average of 1.7
errors per patient daily. A recent survey
of intensive care units in 27 countries
reported 74.5 errors in parenteral drug
administration per 100 patient-days [3],
and this was criticized [4] as represent-
ing significant under-reporting.
The growing complexity of medical
care, the multiplicity of procedures and
medications, the shortening of hospital
stays and of time per ambulatory patient
visit, the large number of individuals
interacting in the care of the patient,
and the increasing economic pressures
have contributed to the increase in the
frequency of dangerous errors in daily
patient care. All indications are that the
present trends will worsen unless major
changes are introduced to stem the tide
of medical error.
The public too has become much
more aware of the problem and is no
longer willing to tolerate the uncon-
scionable toll of human life and suf-
fering, much of which is preventable.
Government agencies and insurance
companies have begun to consider non-
reimbursement for hospital stays caused
described the first "quantum leap" in
the developing "safety culture" as the
limitation of blame. Systems thinking,
transparency, accountability and team-
work are among the other changes that
are required.
The anesthesia field has set an exam-
ple of dramatic improvement in patient
safety over several decades [9] by system-
atic examination of their procedures and
system-wide changes that made previ-
ously common fatal errors almost impos-
sible. Two such examples are the ensur-
ing uniformity of the direction of knob
rotation in all anesthesia machines when
regulating the concentration of anes-
thetic gases. Another major change was
that of changing the connections from
the anesthesia machine to the various
gas lines so that it became impossible to
connect the oxygen line to the anesthetic
gas line. These and other similar changes
would seem so obvious, but many years
passed before they were put into effect.
It took considerable media publicity and
a major culture change in the field for
these changes to be introduced.
In another area of endeavor the remov-
al of ampules of potassium chloride from
resuscitation carts next to ampules of
sodium chloride has saved many lives.
There are certain errors that have
been labeled "never events," those that
should never happen. These include
wrong site, wrong procedure, and wrong
patient operations [10]. Similarly, giving
the wrong type of blood is an example of
a "never" event. Introduction of detailed
procedures to be followed without excep-
tion using checklists can virtually elimi-
nate such errors, in a manner similar to
the kind of checklists used with great
success both in the commercial avia-
tion industry and in combat aviation. A
medical error, quality, patient safety
IMAJ
2009;11:435–436
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