2014: Medical Error

Preventable medical error is a leading cause of death in the US today.

In fact, current estimates place the number of lives lost to medical error at between 210,000 and more than 400,000 a year in the US alone. That would make it the third-largest killer in the US, just behind heart disease and cancer.

Medical error is common but often preventable.

As physician Atul Gawande has pointed out, quality control systems common to other industries—from aviation to the restaurant industry—have evaded the medical profession. Patients and providers alike often suffer from institutional and structural forces that increase the incidence of error, even when those within the system act with the greatest integrity, skill, and good intentions.

“I’m sorry” is an uncommon phrase.

There are many reasons why medical apologies are rare. Physicians feel ashamed and scared. They are often told to stay silent by medical lawyers trying to protect against liability risk. And they aren’t taught how to apologize, which is especially hard to do when the people you hurt are the people you meant to help. Doctors are trained in many skills, like how to intubate a patient or how to calibrate medication dosing—but they are not trained in how to apologize.

This is a problem.

Because if anything is certain in medicine, it is this: Every doctor will make mistakes that end up harming someone. Not because they are incompetent or don’t care, but because they are caring for so many. Even the best doctors, like the best cab drivers, will cause an accident some day, for the simple reason that they are out there day after day, logging mile after mile, and humans aren’t perfect.

On February 6th, 2014, we convened a conversation about medical error.

The conversation drew an audience from across the Georgetown campus and the broader DC bioethics community. Physicians and lawyers, chaplains and businesspeople, many whose lives bear the mark of personal experience with medical error, all came to celebrate a semester of student work on the topic of medical error and to engage in a spirited conversation with patient safety experts that delved deeply into its many moral complexities.

Panel Discussion

Watch the Panel

Listen to the Panel

About the Panelists

John T. James, PhD

Dr. James is former chief toxicologist at NASA, where he received numerous awards and wrote many book chapters and monographs on spaceflight safety. As a result of the loss of his oldest son to medical errors in 2002, he became a prominent patient safety activist: publishing a book in 2007 about his son’s unfortunate care, A Sea of Broken Hearts, and proposing a national patient bill of rights to empower and protect patients. In 2008, he founded Patient Safety America, which is dedicated to the cause of patient safety awareness. He recently published an evidence-based, peer-reviewed study in the Journal of Patient Safety in which he estimated that 440,000 Americans have their lives significantly shortened by preventable adverse events in hospitals. His new book, The Truth about Big Medicine: Righting the Wrongs for Better Healthcare, is set to be published later this year.

Brian Goldman, MD

Dr. Goldman is an emergency physician, author of best-seller The Night Shift, and host of the CBC’s “White Coat, Black Art,” a weekly radio show that takes listeners behind the scenes of hospitals and doctor’s offices. He discusses health care topics ranging from queue-jumping to confronting medical errors and dealing with them—and is not afraid to use his own medical mistakes as examples for how doctors might improve. Dr. Goldman has worked as a health reporter for The National, CBC Television’s flagship news program, for CBC-TV’s The Health Show, and as senior production executive during the launch year of Discovery Health Channel, Canada’s only 24-hour channel devoted to health programming. Dr. Goldman has been a respected emergency physician at Mt. Sinai Hospital in Toronto for more than 20 years. His new book The Secret Language of Doctors—about medical slang and the medical culture from which it arises—will be published later this year.

Beth Daley Ullem, MBA

Ms. Ullem is a prominent advocate for improving the quality of medical care in the US. Following her infant son’s death in 2003, Beth began work on initiatives aimed at reducing preventable hospital errors and improving the transparency of clinical outcomes. She works with hospital leadership teams, hospital boards and healthcare industry leaders to develop and fund programs that reduce risk and improve the quality of patient care in hospital environments, including Harvard Medical School’s Institute of Professionalism of Ethical Practice (IPEP)Northwestern Memorial Hospital, the Center for Medical Simulation, and other leading healthcare institutions. Ms. Ullem is passionate about reducing harm and errors, improving health care transparency, and enabling hospital boards to understand and lead on quality issues.

Gallery: Medical Error

About the Gallery

In 2013, eleven extraordinary students enrolled in a different kind of ethics class.

In fall 2013, KIE director Maggie Little and distinguished visiting professor of design Ann Pendleton-Jullian teamed up to create a very different kind of ethics class—one that used methods from the world of architecture and design to tackle a concrete moral issue.
Alexandra Berg and Jocelyn Fong use wall-based processing to identify moral “hotspots”.
The focus was on medical error; the jointly-taught course took place in the studio setting of the KIE’s Ethics Lab, on the second floor of Healy Hall. Undergraduates from a variety of disciplines—global health, ethics, political theory and linguistics—came together to explore this complex bioethical issue with a toolkit that combined the analytic methods of philosophy with the creative methods of design.

“When we got the syllabus on the second day of class and I saw that I had to purchase colored pencils, a sketch pad, ruler, and special pens that I had never heard of, I was a little frightened,” admits Blake Meza (NHS’15). But he grew to love the class, even if he occasionally found it difficult to describe to others.

It’s amazing how much one class can change how you view so many things.

“It is often difficult to convey to my friends and family what exactly EthicsLab was,” he explains, “and when I tell them it combined ethics and design, they look at me like I am crazy.”

“This was truly a different kind of bioethics class,” says professor of philosophy and KIE director Maggie Little. “Students worked creatively and collaboratively to address real-world roadblocks. Bioethics is about morality, but it’s also about making a difference in the real world, dealing with problems that exist today, not just in abstraction.”

Ethics Lab is a new innovation space on campus whose team-based approach brings together bioethics experts, strategic designers, and those on the front lines of bioethics complexity to make genuine moral impact.

“The work aimed to push our minds beyond traditional patterns of thinking,” says Patricia Cipollitti (SFS’15). “The critical design component isn’t just about drawing diagrams about cases, or making information more easily accessible or prettier—it is genuinely about challenging how we go about thinking about problems and developing potential solutions. We were encouraged to think about medical error at first in localized context, but then in an integrated fashion, incorporating ideas and perspectives from other disciplines.”

Bringing a core Georgetown commitment to life.

The application of this toolkit to real-world moral issues is an exciting new avenue for education and moral progress alike, says Little. “This is a new and powerful way of realizing Georgetown’s Jesuit commitment to engaged ethics.”
Empathy-mapping is one of the techniques used in Ethics Lab, in student work and on outward-facing projects alike.

This work marked the culmination of a semester of intense, creative, critical work that students described as transformative and visiting professional bioethicists and designers described as unprecedented.