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March 06, 2013



Quite frequently as well, errors are a result of system factors rather than due to problems with an individual provider. If the nurse on an acute care unit has too many patients because the hospital refuses to improve staffing, then he or she is more likely to make mistakes, and so forth. The system all too often doesn't take into account the ways human beings operate. Countless times I have worked 12-14 hours without taking a break or eating because I simply didn't have time. Patient acuity was too high and I had too many of them. These are the conditions that permit a mistake to happen. Nobody goes to work with the intention to harm or kill a patient.


This was a good video clip for me to watch... I am living in Asia and sometimes it is frustrating to hear the stories of how many things are corrupt here, and how shady many things are. For example, a friend of ours was almost injected with fluid that had expired some 8 years earlier, and only noticed at the last minute that the medicine was expired. It's easy for me to blame the culture or the nation for these things...but really, the problem is common to the whole world. Sin. Corruption. ALL WE like sheep have gone astray. Someday all things will become transparent before Him...until that day...may we learn to be transparent.
Thanks for the reminder.

Carolyn McCulley

Z.R., I have heard the same thing from many healthcare workers. MedStar's work in human factors engineering is also part of our story - we just didn't get that into our trailer. I appreciate your comment, though.

Heather B

It was a true godsend to come across this blog tonight. As a Christ follower, I am very close to this topic as 18 months ago I almost died from surgeon error during a hysterectomy that led to permanent damage to my urological system. He is a fellow believer and as the 7 month recovery finished I was faced with the financial hardships from his mistakes. I have been torn as to what to do to recover the financial burden and I am in the process of just now contacting him using the process from the Peacemakers website. My guess is because of these systems in place, this doctor will not respond and ill be forced to confront the wrongs through litigation which I truly in my deepest heart do not desire to do. I'm praying for The Lord to do a miracle, and allow us to resolve this between the two of us but it will be a big risk on his part. While The Lord has shown me mercy and allowed me to grow tremendously through this process and I feel grateful to be alive and to have experienced growth through pain and trial, emotionally the scars would be easier to heal if this surgeon and I could find reconciliation and forgiveness across a table. I long for this as I assume this can be terribly painful for the health providers as well. Please pray for a miracle, healing, and restoration in this situation. I know you don't know me from Adam, but I feel tremendous connection to this post and a passion for medical safety and disclosure, as well as Christian Conciliation.


I'm grateful that you are looking into this issue and am eagerly anticipating the rest of this film. As my husband is a doctor going through residency right now, I've heard a bit about this issue and recently attended a grand rounds presentation with him about medical errors and the fear of addressing them. I think the susceptibility to law suits that has run rampant in our culture is a great contributor to this fear. While it is good and necessary for medical providers to have accountability in their jobs as they are dealing with the health and lives of people, the law suits seem to have gotten out of hand. Even though potential risks in medical management options are clearly explained to patients, many patients still feel entitled to positive outcomes and will sue if that is not obtained. And sadly, many medical providers lose time, money, reputation, and even their medical license over such issues. How much greater, then, is the fear of losing everything if something IS their fault and was preventable? Everyone, no matter how cautious or well-meaning, is prone to make mistakes in their lifetime. This is statistically inevitable. It is quite scary and stressful to be serving in the medical field and carrying the weight of others' lives on your shoulders daily. Yes, accountability for and directly acknowledging and addressing error is absolutely necessary to provide quality patient care. I am wondering, however, to what extent is error unavoidable even by the best providers and to what extent should they be "punished" for such errors?


I look forward to seeing the film. As a nurse practitioner in a hospital, I can relate to these issues--the fear of making an error and harming a patient, the desire to be open and honest about what happened if a bad outcome does occur, and the risk of legal problems in such a case. And I can tell you, making an error in patient care, even if the patient is not harmed, is an absolutely horrible feeling. I remember when I was doing agency nursing in a long-term care facility, was working on an unfamiliar dementia unit, and mixed up two patients' medications (realized it before the second one got the wrong pills). I felt awful, and it was hard notifying the first patient's family that such an error had been made (thankfully the patient was fine). The comment about systems issues was right on as well...in my example above there were two patients with the same first name who were roommates, and patients in this facility did not wear ID bands (or at least never kept them on). This is in an environment where many of the patients can't tell you their own name! Yes, there are the photos in the medication book (and I'll be honest, I hadn't looked closely at them because so often they are not helpful), but these are not foolproof--often not up to date.

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