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Oops, Another Teaching Moment


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Oops, Another Teaching Moment

By Jock Hoffman, CRICO

Related to: Ambulatory, Emergency Medicine, Primary Care, Nursing, Obstetrics, Other Specialties, Surgery


Do we really learn from our mistakes? Are stumbles a friendly reminder to watch our step? Is a near miss a gift? Conventional wisdom tells us that improving a process—even in health care—relies on the risks being exposed, understood, and mitigated. This idea isn’t new; in fact people from all walks of life have been talking about it for years.

The first step towards amendment is the recognition of error.
Seneca (b. 4 BC)

It is common error to infer that things which are consecutive in order of time have necessarily the relation of cause and effect.
Jacob Bigelow, MD (b. 1786)

Great services are not canceled by one act or by one single error.
Benjamin Disraeli (b. 1804)

Mistakes are the portals of discovery.
James Joyce (b. 1882)

Every great mistake has a halfway moment, a split second when it can be recalled and perhaps remedied.
Pearl Buck (b. 1892)

Never let the fear of striking out get in your way.
Babe Ruth (b. 1895)

If I had to live my life again, I’d make the same mistakes, only sooner.
Tallulah Bankhead (b. 1903)

When you make a mistake, there are only three things you should ever do about it: admit it, learn from it, and don't repeat it.
Bear Bryant (b. 1913)

I might have made a tactical error not going to a physician for 20 years. It was one of those phobias that didn’t pay off.
Warren Zevon (b. 1947)

Your most unhappy customers are your greatest source of learning.
Bill Gates (b. 1955)

Certainly, no one advocates fomenting errors that endanger patients just to have teachable moments (unless those patients are dummies). But even in high-reliability settings, mistakes prevail. What those who embed patient safety improvement in their organizational culture do promote is the exploitation of those inevitable mistakes—from potential hazards to near misses to malpractice claims. Identify them, analyze them, share the lessons to be learned, and investigate what other departments or organizations facing a similar patient safety risk have done to prevent a reoccurrence. Otherwise, the moment is lost.


December 1, 2009
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