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					                                                                                               Vol. 40, No. 4     245

Literature and the Arts in Medical Education

                                              Johanna Shapiro, PhD
                                                  Feature Editor

                                                Dean Gianakos, MD
                                                 Associate Editor

    Editor’s Note: In this column, teachers who are currently using literary and artistic materials as part of
    their curricula will briefly summarize specific works, delineate their purposes and goals in using these
    media, describe their audience and teaching strategies, discuss their methods of evaluation, and speculate
    about the impact of these teaching tools on learners (and teachers).
       Submissions should be three to five double-spaced pages with a minimum of references. Send your
    submissions to me at University of California, Irvine, Department of Family Medicine, 101 City Drive
    South, Building 200, Room 512, Route 81, Orange, CA 92868-3298. 949-824-3748. Fax: 714-456-7984.

                                   Mistakes and Disclosure
                         Robin O. Winter, MD, MMM; Bruce A. Birnberg, MSW

To err is human, to forgive, divine.      this report, they defined a quality     on teaching a systems approach to
  Alexander Pope1                         health care system as one that is       problem solving instead of focusing
                                          safe, effective, patient centered,      on individual responsibility and
The Institute of Medicine (IOM)           timely, efficient, and equitable.3 In   blame for medical mistakes is part
2000 report, “To Err is Human:            2004, the IOM issued a third report,    of a movement within medicine to
Building a Safer Health System,”          “Patient Safety: Achieving a New        create a patient safety culture. The
focused national attention on medi-       Standard of Care,” that specifically    Institute for Healthcare Improve-
cal errors in hospitals. Utilizing        addressed safety in the ambulatory      ment defines a culture of safety as
previously published data, they           care setting stating that “Patient      “an atmosphere of mutual trust in
estimated that “at least 44,000 and       safety is indistinguishable from the    which all staff members can talk
perhaps as many as 98,000, Ameri-         delivery of quality care.”4             freely about safety problems and
cans die in hospitals each year as           The Accreditation Council            how to solve them, without fear of
a result of medical errors.” 2 The        for Graduate Medical Education          blame or punishment.”6 We have
IOM published a follow-up report          (ACGME) has incorporated a simi-        found that creating this culture can
in 2001 titled “Crossing the Qual-        lar emphasis on patient safety and      be facilitated by training residents
ity Chasm: A New Health System            quality of care into their core com-    to analyze medical mistakes in a
for the 21st Century” that stated,        petencies for residency education       nonthreatening way through the use
“Between the health care we have          under the competency of “Systems-       of film, news media, and examples
and the health care we could have         based Practice.” According to the       from other industries.
lies not just a gap, but a chasm.” In     ACGME, residents are expected              After initially presenting the
                                          to be able to “advocate for quality     safety culture concepts, we then
                                          patient care and optimal patient        apply them to an analysis of the
                                          care systems, work in interprofes-      1971 movie “The Hospital,” which
(Fam Med 2008;40(4):245-7.)
                                          sional teams to enhance safety and      won an Academy Award for best
                                          improve patient care quality, and       screenplay.
                                          participate in identifying systems         “The Hospital” is a satirical com-
From the JFK Family Medicine Residency,
                                          errors and implementing potential       edy starring George C. Scott as Dr
Edison, NJ.                               systems solutions.”5 Their emphasis     Bock, the cynical chief of medicine
246     April 2008                                                                                 Family Medicine

at a major teaching hospital. His       resulted in kidney failure and coma.       In the context of discussing
wife has left him, his children have    After hearing this story, Dr Bock       Jose’s case, we present the Swiss
disowned him, and people are dy-        questions how he can “sustain a         Cheese Model of Error developed
ing mysteriously in his hospital.       feeling of meaningfulness” in the       by James Reason, a British error
Amidst this chaos, Bock becomes         face of such incompetence. In           researcher.8 In this model, a slice of
enchanted with Barbara Drum-            another clip, the wrong patient is      Swiss cheese represents a potential
mond, played by Diana Rigg, who         brought to the operating room for a     barrier to errors such as policies and
has come to take her supposedly         hysterectomy and subsequently dies      procedures, equipment, and team/
comatose father, Edmund, back           from an anesthesia reaction. All of     individual responsibilities. Each of
to the Sioux reservation where the      these seemingly unrelated events        these barriers has potential holes
Drummonds operate a clinic.             are eventually explained in the last    that could align with the holes in
   We show several scenes from          scene we show where we learn that       other barriers in such a way as to
the movie that portray people dy-       the supposedly comatose Edmund          allow an error to slip through. To
ing due to the extreme carelessness     Drummond was really psychotic,          further illustrate this concept, we
and incompetence of the hospital        and had set up the victims to be-       show the residents a video depicting
staff. The first two scenes involve     come patients so that the hospital’s    two well known NASA tragedies
Guernsey, a nursing home patient        systems would kill them. Residents      caused by the failure of multiple
with chronic obstructive lung dis-      related to the movie’s black humor      systems.
ease, who is misdiagnosed with          and the flawed hospital systems that       This video by Chris Valentine
angina and given morphine, which        it satirizes.                           is a retrospective look at the Chal-
ultimately suppresses his breathing        Following the movie, we examine      lenger and Columbia space shuttle
and kills him. Next, a male intern      the tragic series of real-life events   disasters.9 Haunting and without
uses Guernsey’s now empty bed           causing the death of a 2-month-old      narration, it juxtaposes real scenes
for a romantic tryst with a female      child as described in the New York      from each of the disasters with
hematology technician. Afterward,       Times Magazine article, “How Can        background music by Lisa Ger-
the technician leaves, and a night      We Save the Next Victim?” by Lisa       rard and Beethoven. Interspersed
float nurse, mistaking the sleeping     Belkin that the residents had read      throughout the video is artistically
intern for Guernsey, administers        in preparation for this seminar.7       displayed information about the
Guernsey’s medications to the in-       Jose Martinez was brought to the        O-ring failure that led to the Chal-
tern and kills him. Dr Bock labels      hospital clinic for a routine checkup   lenger explosion soon after take-off
this whole sequence of events a         when he was found to be in early        and the loose external tank foam
“Roman farce,” and sarcastically        congestive heart failure due to a       that damaged Columbia and caused
asks if any of the nurses thought       ventricular septal defect. The doc-     its breakup upon reentry into the
to check on the person in the bed       tors recommended starting Digoxin       earth’s atmosphere. This video
“merely on the impression he was        to control his symptoms. The            graphically displays Reason’s Swiss
a patient.” He then yells at the head   resident and attending physicians       Cheese Model of Error and the
nurse, asking her to explain why        calculated the Digoxin dose to be       horrible outcomes that can occur
she uses so many float nurses. She      0.09 milligrams based on the baby’s     when there is a lapse in the culture
responds to the incident by saying,     weight; however, the resident wrote     of safety.
“These things happen.” A hospital       the order for 0.9 milligrams. The          In the final portion of the semi-
administrator looking into the          attending counter-signed the order      nar, we discuss how to disclose
deaths cautions Dr Bock to not do       without catching the mistake. The       errors to patients and the self-care
anything that would jeopardize the      pharmacist, a second resident, and      needs physicians often have after
hospital’s liability. After showing     the nurses who administered the         they have been involved in medical
these clips, we discuss with the        medication all failed to correct the    mistakes. As part of this discus-
residents how these deaths were due     mistake before Martinez received a      sion, we ask residents to share their
to the failure of multiple systems,     lethal dose of Digoxin. This article    personal experiences with medical
as well as to the culture of blame      clearly describes how no single         errors, including their reactions.
and cover-up that is exhibited in       person caused the death of this         Feelings of guilt, embarrassment,
the movie.                              child but how he was the victim         and incompetence were common
   In the next scene of “The Hospi-     of multiple imperfect hospital sys-     along with the understandable
tal” that we use, the chief resident    tems. Our residents found this to       reaction of being hypervigilant
describes to Dr Bock how a patient      be a sobering story because of the      after the mistake. We then explore
with protein in his urine had an        prominent role resident mistakes        the pros and cons of disclosing
unnecessary kidney biopsy for           played in the incident.                 errors to patients highlighting the
research purposes that ultimately                                               ethical imperatives to disclose and
Literature and the Arts in Medical Education                                                                            Vol. 40, No. 4           247

the recommended steps to follow                  Corresponding Author: Address correspondence         6. The Institute for Healthcare Improvement.
                                                 to Dr Winter, JFK Medical Center, 65 James      Ac-
when discussing an error.10,11 We                Street, Edison, NJ 08818. 732-321-7493. Fax:             cessed March 4, 2008.
also emphasize the importance                    732-906-4986.                 7. Belkin L. How can we save the next victim?
of support groups such as Balint                                                                          The New York Times Magazine 1997;June
groups to help physicians cope with                                References
                                                                                                      8. Reason J. Human error: model and manage-
the array of feelings the residents              1. Pope A. An essay on criticism. Part ii, line          ment. BMJ 2000;320:768-70.
expressed when they were involved                   325;1711.                                         9. Challenger/Columbia: retrospective/juxta-
in mistakes.12 We conclude with the              2. Kohn L, Corrigan J, Donaldson M. To err
                                                                                                          intromtt.html. Accessed March March 4,
                                                    is human: building a safer health system.
words of Alexander Pope quoted at                   Washington, DC: National Academy Press,               2008.
the beginning of this paper, remind-                2000.                                             10. Gallagher T, Lucas, M. Should we disclose
                                                                                                          harmful medical errors to patients? If so,
ing the residents of the importance              3. Committee on Quality of Health Care in
                                                                                                          how? J Clin Outcomes Manage 2005;
                                                    America. Institute of Medicine. Crossing
of forgiveness, given our human                     the quality chasm: a new health system for            12:253-9.
propensity to make mistakes.                        the 21st century. Washington, DC: National        11. Herbert PC, Levin AV, Robertson G. Bioeth-
                                                    Academy Press, 2001.                                  ics for clinicians: 23. Disclosure of medical
                                                 4. Aspden P, Corrigan J, Wolcott J, et al. Patient       error. CMAJ 2001;164:509-13.
Acknowledgment: We would like to acknowledge
                                                    safety: achieving a new standard of care.         12. Newman MC. The emotional impact of
the assistance of Nanette Soffen, Rebecca Van
                                                    Washington, DC: National Academy Press,               mistakes on family physicians. Arch Fam
Ness, and Nancy Violette in the preparation of
                                                    2004.                                                 Med 1996;5:71-5.
this manuscript.
                                                 5. ACGME Outcomes Project. www.acgme.
                                                    org/outcome. Accessed March 4, 2008.

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