As I have thought about the upcoming screening of the film on medical errors, I have thought about the following

In 1711, when Alexander Pope published, An Essay on Criticism, he included the phrase, “To err is human, to forgive is Devine.”  Pope was a Roman Catholic.  The adoption of this phrase by religion was to excuse mistakes and mitigate the liability of  sins.   This is the problem with the adoption of this phrase by healthcare leaders who desire to eliminate errors in healthcare delivery.   While we all would assign health care errors to human deficiencies, none of us wish to argue that such errors are essentially inevitable.  We all believe that healthcare transformation can decrease if nor eliminate errors.

The following transformations in healthcare have and continue to contribute to the decreasing of medical errors:

1.  The effective use of electronic medical records
2.  Electronic prescribing of medications including opioids
3.  Frequent and shared medication reconciliations at all points of care and particularly at points of care transitions
4.  Accurate and current medication lists
5.  Effective transitions of care at the eight points of such transitions in routine healthcare delivery
6.  Current, accurate and shared diagnoses lists
7.   Practice accreditation for Ambulatory Care and PC-MH with emphasis upon quality and safety
8.  Routine electronic auditing of provider performance in quality and safety
9.  Public reporting of quality and safety metrics by provider name as one form of transparency
10. Routine and documented sharing of changes in medications, plans of care, diagnoses and treatment plans between healthcare team members including primary care, specialty care, ancillary care and organizations, as another form of transparency

Our tolerance for errors must be zero. We must adopt a culture which applauds admuissions of mistakes, while creating non punitive accountability