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. firstname.lastname@example.org. 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 www.ihi.org/ihi/topics/patientsafety. 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. rwinter@SolarisHS.org. 7. Belkin L. How can we save the next victim? of support groups such as Balint The New York Times Magazine 1997;June 15. 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- position. www.chrisvalentines.com/sts107/ 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.