Joining me today for Episode #329 of the podcast is Mike Eisenberg, the director, editor, and producer of the film “To Err is Human,” a documentary about the incredibly important issue of patient safety. The film shares a title with the groundbreaking 1999 report from the Institute of Medicine.
The film is available on as a digital download (through iTunes and other platforms) and a Blu-ray or DVD (through Amazon) and there also screenings taking place around the country (and you can arrange one at your organization).
Eisenberg was able to interview many people who are very familiar to me, including Dr. Don Berwick, Capt. “Sully” Sullenberger, Dr. Bob Wachter, Leah Binder, Lucian Leape, and others. Endorsements for the film come from some other big names in this movement, including Dr. Atul Gawande:
In our conversation, Mike and I talk about the scale and breadth of patient safety problems, some of the systemic causes, and some of the solutions that are being tried and used in healthcare. The term “Lean” is not a part of the film, but Mike said he's become aware of the alignment between Lean and systemic patient safety improvement, but there are limitations to what could be put into a 77-minute film. But, there are common themes including not blaming “bad apples” and improving the way care is delivered in a systematic way.
I had the opportunity to watch the film before the interview — it's very powerful and well produced. I hope you'll check out the film, whether you are a patient or a healthcare professional (or leader). It's important that we help the public understand that patient safety can't be taken for granted… and it's important that hospitals step up their efforts on this front.
Streaming Player:
For a link to this episode, refer people to www.leanblog.org/329.
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Questions, Topics, and Links:
- The film's official website
- What inspired the film?
- Mike's dad, the late Dr. Mike Eisenberg of AHRQ
- The AHRQ website
- What's the patient safety problem or crisis?
- What's the scale of the problem?
- See various statistics Mark has collected here
- What are the causes of patient safety problems?
- What are some of the things that get in the way of this problem getting fixed?
- What are some solutions that help, as seen in the film?
- What good stuff was left on the cutting room floor?
- The Louise H. Batz Patient Safety Foundation
- How can people arrange a screening at their hospital or some other place? Click to do so
- What do you hope will happen with this film's release?
- Mentioned in the discussion:
- About Sue Sheridan, her son and husband
- Other films: “Bleed Out,” “The Bleeding Edge“
- Threats to AHRQ funding
- His dad, Dr. John Eisenberg – “evidence-based medicine was his passion”
- Surgical / O.R. “black box”
- Buy a Blu-ray or DVD of the film through Amazon
- Watch on YouTube ($)
Some of Mark's Notes and Quotes from Watching the Film:
- Patient safety is a “problem hiding in plain sight”
- The goal is “zero harm,” not “zero errors” — people will make mistakes. We need to assume that errors will happen, so we need to create better systems.
One third of patients will experience an error during their hospital admission- President Bill Clinton made a speech and announcement in 2000 about cutting errors in half (NY Times article from 2000)
- Lucian Leape, MD says patient safety is not a priority for hospital leaders
- If you reduce medical harm, you can't advertise that… you anger the doctors
- We have to reward openness and admission of
errors, so you can learn and improve - Reporting rates drop if nothing is done because reporting is really voluntary even if you tell them to. High reporting rates must mean things are happening or people would stop reporting.
- Leah Binder: Hospitals don't put their Leapfrog letter grade in the front window the way NYC restaurants do
- Sully: Pilots make one error per hour, but they have robust systems
- Dr. Ashish Jha: It's unfair to ask patients to sort this out but the reality is that it's necessary
- Dr. Don Berwick: “It's not a matter of possibility, it's a matter of will.”
Shareable Quotes from “To Err is Human”
Videos About “To Err is Human”
Thanks for listening and please do check out the film.
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Check out my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation:
