The cases at Children’s Hospital Boston making headlines last week, and the heart-lung transplant case at Duke University Medical Center profiled earlier this year, illustrate, yet do not capture a pervasive healthcare crisis. The Institute of Medicine estimates that 50,000 deaths annually in the U.S. may be attributable to medical error. When we analyze these events, we see that unnecessary deaths and injuries are rarely due to a single failure by a single provider. Instead, they originate in, or are allowed to progress because of systemic failures in communication, coordination, and role allocation. Traditionally, response to adverse events has been reactionary, focusing on removal or reprimand of an individual provider, piece of equipment, procedure, institution and even patient. While we may be tempted to sanction individuals in the wake of these tragic events, more durable solutions lie in fixing the ‘system.’ As a first step, we need to identify what aspects of the system contribute to global failure, and proceed from there.
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