Ted R. Melnick, MD


May 19, 2008


I am constantly worrying about making mistakes. Is there any way to minimize errors?

Response From the Expert


Ted R. Melnick, MD
Chief Resident, Department of Emergency Medicine, Mount Sinai School of Medicine, New York; House Staff, The Mount Sinai Hospital, New York, NY



Success is not a destination, it's a journey. The only way to succeed is to be brave enough to risk failure, and to experience it too. If you're going to achieve, it is never going to be one smooth unmarred road. Never. Persistence is the toughness of spirit....Success is measured by the effect that you have on the people with whom you interact.

-- Marv Levy[1]

From 1989 to 1993, Marv Levy led the Buffalo Bills to 4 straight Super Bowls. No other coach in the history of the National Football League has matched his accomplishment. Yet, it is often overlooked because his team actually lost all 4 games. As physicians and medical students, we accomplish countless "victories" in the care of our patients. However, our mistakes and failures are what are often most remembered by our patients and colleagues.

It takes years of training and experience to excel in clinical decision making. But, you can establish good habits early in training that will help to avoid (or at least identify) common pitfalls in clinical decision making. By your 3rd year of medical school, you should be familiar with the medical proverb, "When you hear hoofbeats, think horses, not zebras." This statement is based on the idea that there are 4 types of clinical presentations:

  1. A common disease presenting in a common way (horses);

  2. A common disease presenting in an uncommon way;

  3. An uncommon disease presenting in a common way; and

  4. An uncommon disease presenting in an uncommon way (zebras).

Although we can learn a lot from the fascinating zebras, we will spend most of our careers identifying and caring for horses. After seeing horse after horse, we develop pattern recognition and must be careful not to automatically identify every case as a horse, potentially failing to recognize a true zebra. Pat Croskerry[2] writes extensively about such "cognitive biases," and he offers strategies to help avoid errors in clinical decision making.

Being human, though, physicians are not infallible. So, what happens if we make a really big mistake that results in a bad patient outcome? The department or hospital will have a Quality Assessment (QA) or Performance Improvement (PI) group review the case. These cases often end up being presented in Morbidity & Mortality (M&M) conferences. Attending a QA or PI meeting or an M&M conference is a great way to get exposure to how physicians approach their mistakes and what they do to prevent them in the future.

The landmark Institute of Medicine report, To Err is Human,[3] found that as many as 98,000 Americans die annually from preventable medical errors. In addition, these errors cost American hospitals as much as $29 billion annually:


"One of the report's main conclusions is that the majority of medical errors do not result from individual recklessness or the actions of a particular group -- this is not a "bad apple" problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them....Thus, mistakes can best be prevented by designing the health system at all levels to make it safer -- to make it harder for people to do something wrong and easier for them to do it right. Of course, this does not mean that individuals can be careless. People still must be vigilant and held responsible for their actions. But when an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error."

The airport industry has managed to limit mistakes to about of 1 in 10,000 (except when it comes to baggage, of course!), yet our healthcare system struggles to reach the order of 1 in 100 mistakes. Most people attribute the high number of medical errors to the complexities of any individual case and the countless human factors involved in delivering care to each patient.

What can we do to minimize our mistakes? Some of the most disastrous medical errors are actually preventable. For example, most adverse drug events, improper transfusions, surgical injuries and wrong-site surgeries, and mistaken patient identities can be attributed to communication lapses. The Joint Commission's National Patient Safety Goals address methods to prevent mistakes with better patient identification, patient handoffs, medication reconciliation, identification of look-alike/sound-alike drugs, and avoiding certain abbreviations.[4,5] Becoming familiar with these safety strategies can go a long way toward avoiding preventable errors.

In addition, all those case presentations that you do on rounds as a medical student offer a chance to learn to give an effective, well-communicated patient handoff. This lays the foundation for effective communication and teamwork throughout your career.

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