Doctors' Deadly Mistakes

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here are probably hundreds of other improvements that could reduce the chance of human error--but they can't be designed unless those errors come to light. And that won't happen unless doctors and nurses are willing to admit to their mistakes. That can be psychologically tough. Medical professionals, observes Dr. Nancy Dickey, former president of the A.M.A. and National Patient Safety Foundation, "have to have the audacity to make decisions that involve life or death. It's difficult to train those same people to be open about how they make mistakes."

It can also be expensive for them to do so. Doctors routinely pay $60,000 a year for malpractice insurance, and while some trial lawyers insist that lawsuits are what keep physicians and hospitals from making errors, it's hard to believe that fear of litigation is the most effective way to enforce medical standards.

Many hospitals are so concerned with cutting down on preventable errors, though, that they are ignoring the risk of malpractice claims and doggedly rooting out their mistakes. Even in the hours before Ben Kolb died, for example, Martin Memorial hospital's risk-management director Doni Haas had launched an investigation, sealing off the operating room and seizing the syringes, instruments and medications used in the procedure. She could do this without being obstructed, she says, because the hospital staff was focused on finding the cause of the problem and preventing such a thing from happening again.

It took Haas 3 1/2 weeks to discover what killed the boy, and at that point she went to see Ben's parents and the attorney they had retained. "I told them we had saved the syringes," she says, "and had them tested, and that we accepted full responsibility for the error, and we were very, very sorry." The case was settled that evening.

All these efforts are laudable, but unless they are universally adopted, patients will continue to die--not through gross negligence or incompetence but through plain human error. "This is a wake-up call," says Arthur Levin, director of the Center for Medical Consumers, based in New York City, and a member of the committee that wrote the new report. "The American health-care system has not put safety at the top of its agenda. Generally, they say this problem doesn't exist. But this is not an aberration. It's an all too common occurrence. And it is unconscionable to allow it to go on."