A Medical Error, Then a Suicide

Everyone makes mistakes. So how can health care prevent errors from harming patients? In a new video, Dr. David W. Bates, Chief Innovation Officer at Brigham and Women’s Hospital, explains why health care is now working to improve patient safety by reducing harm, not just error. Dr. Bates also offers his thoughts on one definition of harm that was used in the Harvard Medical Practice Study, one of the seminal research projects on the epidemiology of medication error.

Have you ever tried to explain quality improvement to the uninitiated? It’s not easy. Dr. Don Goldmann, IHI Chief Medical and Scientific Officer, offers his advice on how to make an elevator pitch without your listener’s eyes glazing over. “My advice is first to get people’s attention, and even an extra minute or two, by showing how QI is relevant to them,” Goldmann writes. “I’d ask your colleague what makes her angry at work — perhaps what’s had her gnashing her teeth that very day.” Read more from Dr. Goldmann here, and consider trying out your QI pitch when trying to get other students interested in joining your Open School Chapter.

Kim Hiatt had worked as a nurse for 24 years when she made her first medical error: She gave a frail infant 10 times the recommended dosage of a medication. “Miscalculated in my head the correct [dosage] according to the mg/ml,” she wrote in the patient’s record — right before being escorted from the hospital building and told to stay away and not call. Five days later, the baby died. Hiatt was fired. Seven months after her error, Hiatt killed herself. “This is a story about Hiatt,” writes Vox, “the mistake she made, how she struggled with that tradegy, and how the institutions that had previously supported her ultimately shut her out.” Learn more about caring for second victims in PS 105: Communicating with Patients after Adverse Events.