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Medical error: An acceptable level of risk?

Yale Medicine Magazine, 2018 - Winter


Susan Sheridan looks directly at the viewer and tells her story: Medical mistakes left her son with cerebral palsy, and cost her husband his life after a test showing malignant brain cancer was never reviewed by his physician.

“It was hard for us to understand and believe that this could happen in a developed country like the United States,” Sheridan says to the camera.

Sheridan and her family’s story are the spine of a new documentary film that takes an unsparing look at medical errors. Screened last month for a standing-room-only audience of Yale New Haven Hospital and School of Medicine clinicians and administrators, To Err is Human is tentatively slated for a fall release. It claims that medical mistakes are the third leading cause of death in the United States after heart disease and cancer, resulting in as many as 440,000 preventable deaths year.

“That is the equivalent of seven or eight airliners crashing every day with no survivors,” says one expert interviewed in the movie.

After the film, a panel that included Yale New Haven Health System President and CEO Marna P. Borgstrom, MPH, and Michael Eisenberg, one of the filmmakers, engaged in a lively discussion with the over 100 medical professionals and administrators who packed the screening.

“I think this an amazing project that once you get this to the public you are going to have an incredible impact in all of health care,” Borgstrom told Eisenberg. “There isn’t anything more important.”

Also on the panel was Sally Roumanis, RN, who told of her husband’s death at Yale New Haven Hospital after interns failed to recognize he was in distress following a heart procedure. Roumanis likewise praised the film and said that hospitals and doctors needed to admit mistakes more readily and work harder to prevent future ones.

While it has plenty of bad news about medical mistakes, To Err is Human also has good news. The film depicts new and innovative efforts to reduce medical mishaps, such as role-play in which practitioners work with actors and learn to admit errors. The movie touts the airline industry’s remarkable safety record as a template for hospitals and doctors, providing inspiration for another innovation portrayed in the film: A surgical “black box” similar to that used by commercial aircraft to record every detail of a procedure so it can be reviewed later.

The documentary also traces the transformation of Sheridan family from victims to influential and respected advocates for greater patient safety.

Filmmaker Eisenberg was originally attracted to the project because his late father, John M. Eisenberg, MD, ran the federal Agency for Healthcare Research and Quality, which is charged with reducing medical mistakes. Eisenberg’s father died of brain cancer in 2002 at the age of 55. To Err is Human is his son’s first full-length documentary.

Eisenberg, who is based in Chicago, said he initially planned to focus on the agency his father ran but soon realized there was a much bigger story to tell. The documentary ended up taking three years to make, with Eisenberg and his fellow filmmakers raising most of the money themselves, said.

“It was very much a passion project,” Eisenberg, 33, said.

Left largely unexplored in the film is the role of litigation in making doctors and hospitals reluctant to admit mistakes. During the panel discussion after the film’s screening, several speakers acknowledged they had been trained to not admit to errors because of fears about lawsuits.

Ken Ferrucci, senior vice president of government affairs for the Connecticut Medical Society, said that his organization wants to see fewer mistakes but called the current medical liability system an obstacle to that goal. Lawyers, patient advocates, and medical professionals need to talk frankly about how to balance “making patients whole when there is a mistake with encouraging transparency and review that strengthens the system,” Ferrucci said.

The filmmaking team chose to focus on errors and how to prevent them instead of the litigation, a subject so sprawling it would require a second film, Eisenberg said.

“What I do understand is that lawsuits create transparency, and I think that is a good thing,” he said. “But I don’t think it’s good thing if it causes doctors to act reactively as opposed to proactively. If people in medicine are doing what they are doing to not get sued, they are likely not doing it for the right reasons.”

The filmmakers have been screening the movie at medical schools and hospitals nationwide to get input and gauge reaction, Eisenberg said. His goal is not only to get doctors to admit errors—two do so on camera in the movie—and work to reduce them, but also to educate patients. He wants patients to feel comfortable requesting doctors wash their hands if they fail to do so and asking the contents of an IV bag about to be administered to them or a loved one, Eisenberg said.

“Those are easy things for patients to pick up on their own,” he said.

Eisenberg said the next steps are screening the movie at film festivals and getting placed on a streaming platform in the fall.