
At this year's British Open, American golfer Tom Watson captured the world's attention. If he had won at age 59 he would have been the oldest winner of the championship.
He captured my attention after he narrowly lost. Watson could have blamed his caddy, his clubs, or loud fans for his defeat. Instead he said, "I put myself in a position to win but I did not get it done." He admitted that the errors leading to his defeat were his alone.
If only more physicians had that same sense of responsibility about owning up to medical errors. It's easy, for example, to shrug off hospital infections. But we know that many such infections can be prevented if medical personnel are guided by established procedures, use antibiotics properly, and follow the rules each time.
A decade ago, the Institute of Medicine published "To Err Is Human," a ground-breaking report that focused on the epidemic of medical errors in the U.S. Some of the nation's most respected physicians wrote it, and many doctors endorsed it. The report recommended changing hospital and physician practices to reduce errors. Those recommendations included publicly disclosing errors and safety concerns.
Since then, billions have been spent studying the problem, but not much has changed. (See Consumers Union's recent report "To Err Is Human—to Delay Is Deadly".) Tens of thousands of people continue to die each year because of errors, and in most states consumers still have no access to information about rates of infection and medical harm that occur in various hospitals. Disclosure of errors to individual patients or families is rare.
Sometimes it's difficult or impossible to determine who or what was responsible for a medical mistake or hospital-acquired infection. But often we know that an error was the culprit, not the disease or the patient. Administrators worry that if they acknowledge errors, doctors and staff will be afraid to report them. But is that fair to patients who might have been harmed? They deserve to know what happened and that the doctor or hospital is trying to rectify the situation. They also deserve an apology from staff who take responsibility for the error and commit to doing everything possible to limit the effect on the patient.
Until our health-care system gets its act together, patients and their families will have to be constructively assertive to get to the bottom of any mishaps.