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Jacob Blackman
English 1103
Professor Campbell
2 November 2016
Medical Mistakes: Striving Towards Perfecting an Imperfect Science
I will never forget the day I was throwing a baseball with my father when I received news
about my grandfather. A few days earlier, I had called Grandpa Jack to check on him, and told
him I could not wait to go fishing with him again later that summer. Tragically, that fishing trip
never came to fruition. After overcoming his bout with prostate cancer, my grandfather perished
from an undetected blood clot that prevented blood from flowing to his heart resulting in a
massive heart attack. The news was devastating to both myself and my family. We were not only
consumed by grief, but also found ourselves shocked that he had survived cancer, yet died of
something clearly preventable like a blood clot. We later discovered that the doctors in charge of
treating my grandfather had failed to communicate properly with one another, and decided not to
administer the proper blood thinners to him. This proved to be a fatal mistake, as Grandpa Jack
had very viscous blood leading to a higher risk of potential heart problems. While these
physicians could not alter the fact that my grandfathers blood was very thick, through improved
communication and proactive measures, there is a higher likelihood that I could still be fishing
with Grandpa Jack today.
Every year, millions of people throughout the United States enter hospitals seeking
treatment for a variety of diseases and illnesses. While hospitals attempt to view patient safety
with upmost importance, recent evidence shows that medical errors still frequently occur within
U.S. hospitals. In 1999, the Institute of Medicine reported that nearly 98,000 people perish each

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year due to mistakes made within hospitals. Transitioning forward, in 2014 the Journal of
Patient Safety reported that this number may be even higher. In fact, the report suggested that
between 210,000 and 440,000 patients who seek treatment from hospitals suffer some type of
preventable harm that leads to their death (James). To provide comparison, the number of deaths
that result from car accidents is approximately 46,000, and those that result from workplace
accidents is nearly 11,000 (Medical Malpractice). As stated by John T. James, a toxicologist at
NASAs space center in Houston, who maintains an advocacy organization called Patient Safety
America, the total number of deaths from care in hospitals is roughly one-sixth of all deaths that
occur in the United States each year (qtd. in Allen). These numbers are staggering, and clearly
evidence the fact that medical errors pose a direct threat to the well-being of all patients. While
the sheer death toll that results from errors made in hospitals is compelling evidence, the issue
gains even more significance after we explore the economic burden of injuries that arise from
medical mistakes. Using information found in surveys of injured patients, in 1984, investigators
estimated that adverse events among patients hospitalized in New York led to nearly $4 billion in
total health care costs (Johnson et al.). Then, in 2008, medical errors cost the United States
nearly $19.5 billion (Andel et al.).
As we now understand the financial implications of medical mistakes, it is important to
explore why errors continue to persist within our healthcare system. We must also examine a few
of the preventative measures being taken by hospitals to address the issue of medical errors, and
how these techniques may bring about improvements in patient safety.
In a culture where technology and medicine are both highly researched and valued, why
do medical errors continue to persist in modern healthcare? Historically, it has often been
challenging to properly study errors in medicine because of the confusion that arises from

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different interpretations of what constitutes an error. To resolve this, it is important to establish a
clear definition of the term medical error. Errors in medicine have, more recently, been defined
as the failure of a planned action to be completed as intended, or use of a wrong plan to achieve
an aim; the accumulation of errors results in accidents (Kohn et al.). While we have seen the
devastating impact of these mistakes, or adverse events as physicians call them, we must now
explore why they originate. To accomplish this task, it is helpful to examine the environment in
which physicians often treat their patients. As will be seen, there are a few psychological and
workplace factors that play a key role in creating an environment where serious medical mistakes
are more likely to occur.
The correlation between stress placed on doctors from their environment, and the
frequency of mistakes was first discussed in 1988. Reported in the Journal of Applied
Psychology, workplace and personal stress adversely affect physical and cognitive functioning,
thus impairing health care judgements, decision making, and behaviors that lead to [errors]
(Jones et al.). While conducting research on stress and medical malpractice, the group that
produced this report found that stress negatively impacts the performance of physicians. This
finding is significant as more recent research supports the view that physicians and other health
care workers have higher levels of stress and burnout than other professionals (Weinberg and
Creed).
The fear of unintentionally harming their patients during operations could negatively
impact physicians performance as stress levels rise, thus perpetuating the issue of committing
mistakes (Schroeder and Sohn). These stress levels rise as doctors begin to experience the fear of
becoming humiliated while on the job. As stated by Dr. Danielle Ofri, who practices at Bellevue
Hospital and teaches at New York University School of Medicine, doctors work under a culture

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of perfection (Fear of Humiliation). Dr. Ofri expressed that doctors select [medical students]
for perfection and then teach them perfection (Fear of Humiliation). Essentially, the point
Dr. Ofri attempts to address is the fact that because perfection is something preached within the
culture, many physicians fear becoming humiliated if they mention any errors they may have
conducted while treating patients. Since this fear is so powerful in their minds, physicians
become less inclined to share their mistakes with their peers, and conversations are smothered.
This, in turn, negatively impacts the problem of medical errors because as conversations are
hindered, doctors do not share what they learned from their mistakes, which could be beneficial
to another physician in the future who may deal with a similar situation while treating a patient.
Since stress leads to a higher likelihood of making medical errors, it is important to
identify additional factors that facilitate stress. The limitation of resources is a factor that leads to
more stressful environments in which doctors must practice. As more hospitals shut down, and
employees and budgets are reduced, the few remaining physicians must deal with massive
workloads on a day-to-day basis.
With an accumulation of stress, many physicians find themselves experiencing burnout,
or a state of emotional exhaustion in which [physicians] view [patients] impersonally and their
own performance disparagingly (Leiter). If we begin to consider the fact that burnout leads to
emotional exhaustion and reduces a physicians desire to truly care about his or her job, it is not
difficult to imagine how this could lead to a lack of focus. Tragically, even the slightest slip in
focus can be the difference in increasing the longevity of a patients life and ending a life
prematurely.
For instance, the late Marilyn Bogner, who was the Chief Scientist of the Institute for the
Study of Human Error, shed light on how devastating these lapses in focus can be by sharing a

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story of a very fit, successful man who died tragically in a hospital (Bogner). The man had
entered the hospital to have minor surgery conducted on his heel after injuring it while running.
Evidently, according to Bogner, this surgery was simple and should have resulted in no
complications. Unfortunately, after being anesthetized, doctors used an intubator to help the man
breathe. This is the step where the medical error occurred. The physicians performing the surgery
accidentally placed the tube in the mans esophagus, which is a part of ones digestive tract,
instead of in his trachea, which is where breathing is facilitated. As a result of the incorrect
intubation, the man died due to suffocation air was traveling to his stomach rather than his
lungs. As stated by Bogner, the tragedy worsened when the mans wife also passed away within
a month, likely due to her grief over the loss of her husband. Ultimately, the preventable medical
mistake made by the physicians performing surgery on the man resulted in the unnecessary death
of a young couple, and forced their children into an orphanage.
Fatigue and sleep deprivation also influence a physicians likelihood of committing a
mistake while practicing medicine. Sleep loss appears to result in reduced reaction time,
decreased vigilance, [and] perceptual and cognitive distortions, writes Kreuger in Sustained
Work, Fatigue, Sleep Loss, and Performance: A Review of the Issues. Relating this to
physicians performance, clinical tasks that require the most focus and concentration tend to be
the most challenging for residents to perform effectively if they are fatigued or deprived of sleep
(Samkoff and Jacques). As many residents are asked to work nearly eighty hours per week
increasing the probability of fatigue the likelihood of these individuals making mistakes while
on the job also increases.
Another factor that plays a significant role in the production of medical mistakes is the
complexity of information at the disposal of modern physicians. While technological

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advancements, especially those created after World War II, have directly benefited medicine, one
consequence of this advancement has been the sheer amount of information being made
available to doctors. Throughout history, physicians have always dealt with the issue of being
uncertain upon diagnosing a patient medicine is an imperfect science. The issue with increased
and accessible information is that with too much information, a doctor can become overloaded
and unable to truly process the information effectively. Interestingly, according to research
conducted by psychologists, humans cannot simultaneously distinguish between more than seven
discrete entities, or hold more than that number in their short-term memory (Svensson et al.).
Consider, for a moment, why it is sometimes challenging to recall a phone number or items from
a grocery list that are not written down. The reason behind why this task can be difficult stems
from the fact that remembering approximately seven items is the typical capacity of what is
called the brains working memory (Schenkman). With this being said, additional research has
shown that doctors are actually more likely to refrain from prescribing medication to a patient if
there are two types of medication available for them to select. This is very intriguing because
these same physicians would prescribe medication to their patients if they only had one drug as
an option (Redelmeier and Shafir). Evidently, the challenge of having to choose between two
different drugs has the contradictory effect of keeping the doctors from selecting any medication
at all (Redelmeier and Shafir). This example illustrates how the complexity of information can
alter the decisions of doctors decisions that directly impact the well-being of their patients.
Medical mistakes are, unfortunately, inevitable. As physicians are human, it is impossible
to expect absolute perfection from them while on the job. While some adverse events are truly
unpredictable, quite a few patients are often left injured in modern hospitals as a result of
preventable errors made by doctors. As we have examined some of the reasons as to why doctors

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continue to make these mistakes, it is also helpful to explore some of the ways in which hospitals
are attempting to minimize the frequency of these mistakes.
To begin, many healthcare institutions are seeking to address the high frequency of
medical errors by mirroring the aviation industry. Since the healthcare and aviation industries
involve highly skilled professionals working with advanced technology, both fields have high
risks of the occurrence of errors between technology and the users. Adopted from the aviation
industry, hospitals now utilize preoperative and postoperative briefings, simulator training,
checklists, annual competency reviews, and incident reporting (Rodriguez et al.). These
techniques help physicians identify and communicate problems more efficiently, develop backup plans in case things go wrong, and facilitate the resolution of conflicts. Most importantly,
research evidences that the adoption of these methods leads to fewer postsurgical infections and
quicker patient recovery (Rodriguez et al.).
In addition to adopting some of the techniques from the aviation industry, many hospitals
are also attempting to improve their management of medications. As Shelly Weatherly, the vice
president of Risk Education and Evaluation Services for Tennessees State Volunteer Mutual
Insurance Company, contends maintaining a well-documented medical record is vital both from
a patient care and risk management standpoint (Sanders). To ensure the safety of patients, and
reduce the probability of the occurrence of medical errors, physicians should update the
medication history of their patients at each visit, and discuss risks, side effects, and alternatives
to prescribed medications (Sanders).
For a specific example of how hospitals are beginning to curb the frequency of medical
errors, it is important to analyze the Chicago hospital system. Recently, hospitals in the city of
Chicago emphasized that revealing medical errors helps construct a safer health care system.

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These hospitals adopted a process known as the Seven Pillars that consists of a few steps.
Highlighting a few of these pillars, the hospitals strive to report incidents that could harm
patients, communicate when an error occurs, track data from patient safety reports to see if
changes improve safety, and educate staff on how to provide safe care (Clancy). This process
has been proven to be effective in Chicago because improvements in reporting, and the
establishment of an environment of learning have allowed the hospitals the opportunity to
pinpoint and correct patient safety concerns (Clancy). This has helped reduce future mistakes
from occurring because more physicians have revealed their errors and thus helped the entire
health care team become more proactive in case the circumstances ever arise again in the future.
This process has also been very beneficial to physicians in these Chicago hospitals because
rather than simply placing blame on the doctors, more time is spent on identifying why an error
occurred in the first place, and action can be taken to make sure that the error does not occur
again.
With a better understanding of why medical errors continue to occur frequently, hospitals
can begin to identify some of the factors within their environments that are likely to contribute to
the occurrence of mistakes. To facilitate the reduction of the sheer number of errors, hospitals
can implement new action plans that include techniques devised to improve communication
and reduce the high levels of stress that many doctors experience. Although believing in the
complete eradication of medical mistakes is irrational as humans are imperfect creatures with
the proper implementation of preventative techniques, hospitals can minimize medical mistakes
and better protect the safety of patients. Questions remain about how quickly hospitals,
particularly in rural areas, will adopt new action plans. If physicians working in these poorer
areas would choose to utilize preoperative and postoperative briefings, checklists, and annual

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competency reviews, conversations between doctors would be encouraged. By facilitating these
conversations, rather than stifling them, communication among all members of the health care
team would drastically improve and the safety of more patients would be ensured. Generally
speaking, most American hospitals are beginning to promote a change in their environments
towards developing a culture where doctors can communicate effectively with one another, and
patients are well-informed of the particular details pertaining to their treatment. With more
efficient communication and transparency, doctors can limit their mistakes, and patients can be
reassured that they are receiving the best care possible.
As I reflect on the death of my grandfather, I am still saddened by the fact that he died
from a preventable mistake made by doctors who neglected to fully examine his medical record.
While I am thankful that I still retain many wonderful memories of him from my childhood, the
error committed by my grandfathers doctors prevented him from seeing my high school
graduation, and other important milestones in my life that would have made him proud. Even
though the frequency of medical errors is still a significant issue plaguing modern hospitals in
the United States, there is hope for the future safety of patients as more and more hospitals begin
to implement new action plans. If all goes well, as more hospitals begin to address their errors
and seek to find ways to prevent them from happening again in the future, fewer children will
have to face the tragedy of losing a cherished relative.

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Works Cited
Allen, Marshall. How Many Die from Medical Mistakes in U.S. Hospitals? Scientific
American. 20 Sept. 2013. ProPublica. Web. 15 Oct. 2016.
Andel, C., Davidow, S. L., Hollander, M., and Moreno, D.A. The Economics of Health Care
Quality and Medical Errors. Journal of Health Care Finance, vol. 39, no. 1, 2012, pp.
39-50. PubMed Central. Web. 15 Oct. 2016.
Bogner, Marilyn S. Human Error in Medicine. Lawrence Erlbaum Associates, Inc., 1994.
Clancy, Carolyn. Revealing Medical Errors Helps Chicago Hospitals Build a Safer Health
System. Agency for Healthcare Research and Quality. 10 Jul. 2012. U.S. Department of
Health and Human Services. Web. 21 Nov. 2016.
Fear of Humiliation Leads to Mistakes, Doctor Says. Minnesota Public Radio News. 9 Jul.
2013. Web. 21 Nov. 2016.
James, John T., A New, Evidence-based Estimate of Patient Harms Associated with Hospital
Care. Journal of Patient Safety, vol. 9, no. 6, 2013, pp. 122-128. Wolters Kluwer Health.
Web. 15 Oct. 2016.
Johnson, W. G., Brennan, T. A., Newhouse, J. P., Leape, L. L., Lawthers, A. G., Hiatt, H. H.,
and Weiler, P. C. The Economic Consequences of Medical Injuries. Journal of the
American Medical Association, vol. 267, no. 18, 13 May 1992, pp. 2487-2492. PubMed
Central. Web. 15 Oct. 2016.
Jones, J. W., Barge, B. N., Steffy, B. D., et al. Stress and Medical Malpractice: Organization
Risk Assessment and Intervention. Journal of Applied Psychology, vol. 73, no. 1, 1988,
pp. 727-735. Web. 15 Oct. 2016.

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Kohn, Linda T., Corrigan, Janet M., and Donaldson, Molla S. To Err Is Human: Building a
Safer Health System. Institute of U.S. Medicine Committee on Quality of Health Care in
America. 2000. PubMed Central. Web. 15 Oct. 2016.
Krueger, Gerald P., Sustained Work, Fatigue, Sleep Loss, and Performance: A Review of the
Issues. Work and Stress, vol. 3, no. 2, 1989, pp. 129-141. U.S. Army Aeromedical
Research Laboratory. Web. 15 Oct. 2016.
Leiter, M. The Dream Denied: Professional Burnout and the Constraints of Human Service
Organizations. Canadian Psychology, vol. 32, no. 4, 1991, pp. 547-558. ResearchGate.
Web. 15 Oct. 2016.
Medical MalpracticeBy the Numbers. Civil Justice Resource Group. 2010. Web. 15 Oct.
2016.
Redelmeier, D. A., and Shafir, E. Medical Decision Making in Situations that Offer Multiple
Alternatives. Journal of the American Medical Association, vol. 273, no. 4, 1995, pp.
302-305. PubMed Central. Web. 15 Oct. 2016.
Rodriguez, Maria A., Courtney D. Storm, and Howard A. Burris. Medical Errors: Physician and
Institutional Responsibilities. Journal of Oncology Practice, vol. 5, no. 1, 2009, pp. 2426. PubMed Central. Web. 10 Oct. 2016.
Samkoff, J. S., and Jacques, C. H., A Review of Studies Concerning Effects of Sleep
Deprivation and Fatigue on Residents Performance. Academic Medicine, vol. 66, no.
11, 1991, pp. 687-693. PubMed Central. Web. 15 Oct. 2016.
Sanders, Cindy. Malpractice: Primary & Secondary Prevention. Nashville Medical News. 16
Sept. 2016. NewsBank. Web. 10 Oct. 2016

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Schenkman, Lauren. In the Brain, Seven is a Magic Number. ABC News. 6 Dec. 2009. ABC
News Internet Ventures. Web. 21 Nov. 2016.
Schroeder, Amanda, and Sohn, David H. Medical Malpractice: Myth Vs. Fact. American
Academy of Orthopaedic Surgeons Now, vol. 9, no. 12, 2015, pp. 30-31. Academic
Search Complete. Web. 10 Oct. 2016.
Svensson, E., Angelborg-Thanderz, M., Sjoberg, L., et al. Information Complexity: Mental
Workload and Performance in Combat Aircraft. Ergonomics, vol. 40, no. 3, 1997, pp.
362-380. PubMed Central. Web. 15 Oct. 2016.
Weinberg, A., and Creed, F. Stress and Psychiatric Disorder in Healthcare Professionals and
Hospital Staff. Lancet, vol. 355, no. 9203, 12 Feb. 2000, pp. 533-537. PubMed Central.
Web. 15 Oct. 2016.