by Jerome Groopman, MD

Doctors, like business leaders, make mistakes. Some errors are purely operational. A pint of blood is mistakenly transfused into Joan Smith rather than Jane Smith, and Joan goes into shock. A young doctor writes an incorrect dose of chemotherapy on an order sheet, and a woman with breast cancer dies from the toxic effects of overtreatment. A neurosurgeon operates on the wrong side of the brain because an X-ray was mislabeled as "right" rather than "left." These kinds of errors make headlines, trigger lawsuits, and terrify patients and their families; in the academic world, such mistakes prompted the Institute of Medicine to publish the landmark article "To Err Is Human" in 1999. Leaders in health care took the IOM recommendations to the business world for solutions. Lessons learned in high-risk industries such as air travel and nuclear energy were applied to hospitals. Anyone who has recently had a medical procedure or treatment has benefited from the checks and double checks that have become routine. To ensure that the right patient receives the intended care, health care professionals, like airline pilots, now follow strict protocols.