The Faces of Errors: A Case-Based Approach to Educating Providers, Policymakers, and the Public About Patient Safety

Background

When patient safety became a subject of policy and research, the question was how to engage clinicians—perhaps they would respond more to case studies of dramatic adverse events than to statistics.

The Chronology

In 2001, we launched a case-based series in the Annals of Medicine which focused on diagnosing what ailed the system rather than the patient. For example, in “The Wrong Patient,” 17 discrete errors resulted in a woman’s receiving a cardiac electrophysiology procedure intended for another patient with a similar last name. The Web-based Agency for Healthcare Research and Quality (AHRQ) WebM&M was then developed as a forum that was part-reporting system and part-journal. Finally, we then applied this approach to writing a book for a popular audience.

Lessons Learned

We found that clinicians were willing to submit cases, assuming that anonymity was protected. Cases of errors that led to harm were generally more compelling than near misses. As in real life, many cases lacked complete information, but sufficient information was usually available to highlight the key lessons. All three vehicles generated substantial readerships and critical praise, indicating that there is a “market” for case-based education about patient safety.

Conclusion

Presenting de-identified cases of medical mistakes in a variety of public venues is an effective way to educate patients and providers about safety.