Why Do We Fail at Reducing Medical Errors? Assuming Responsibility to Leverage Failure into Improvement.
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CONTEXT: Medical errors are the third leading cause of death after heart disease and cancer, but in contrast to these conditions, progress in reducing mistakes has been minimal. PERSONAL EXPERIENCE AND LEARNING: I learned firsthand about barriers to improvement during events surrounding the death of my grandson, who had a complex heart defect missed on a pregnancy ultrasound. Following his tragedy, universal pulse oximetry screening was implemented at a national level, probably saving dozens of children from a similar fate every year in our country. BARRIERS TO IMPROVEMENT: On the other hand, I also found a refusal to link failure with correction. Lawyers working for the HMO where ultrasound had missed the heart defect claimed that the practice was reasonable, rejecting responsibility for the failure and quest for improvement, such as considering adoption of AI for enhanced diagnostic accuracy. Pulse oximetry universal screening could have been implemented a decade ago (thereby preventing our tragedy). Still, the people in charge at a National Council then did not listen to the committee of experts they had appointed and who recommended the screening. INSIGHTS: Linking errors with improvement brings meaning to suffering: the tragedy would not have been in vain if it had motivated corrective actions. Communication failure is responsible for most errors, and a significant barrier is the fear of speaking up. The lesson was tragically learned at NASA and other organizations, emphasizing the importance of listening to everyone to prevent disasters. Respectful listening is an essential key to cooperation and success. CONCLUSION: Healthcare needs a paradigm shift to a culture of transparency, responsibility and collaboration, building growth from past failures, learning from mistakes to improve patient safety.