According to the report, Dr. Berwick has spent his career watching physicians and nurses “making dangerous and expensive mistakes in systems that set them up to fail.” He said physicians and nurses work long hours, making them more susceptible to inevitable human error. These errors can have dire consequences when patient lives are at stake, not to mention the toll they take on the national checkbook.
Thirty years ago, the aviation industry revamped its system of checks and balances after a series of fatal crashes was linked to errors by distracted flight crews. Dr. Berwick is trying to lead a similar movement in healthcare by encouraging hospitals to implement checklists, protocols and “best practices” that limit unnecessary medicine and catch mistakes before they become serious.
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