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Analysis

To Err Is Human Film Urges Patient Safety Improvement

By Christopher Cheney  
   January 25, 2019

Patient safety deficiencies are spotlighted in a new documentary.

One of the most influential reports on patient safety has inspired the production of a documentary film.

In 1999, the Institute of Medicine published "To Err Is Human: Building a Safer Health System," which included the alarming statistic that as many as 98,000 Americans were dying annually due to medical errors. Estimates of annual patient deaths due to medical errors have since risen steadily to 440,000 lives, which make medical errors the country's third-leading cause of death.

This week, the son of patient safety pioneer John Eisenberg, MD, is making the general public release of To Err Is Human, a documentary film inspired by the Institute of Medicine report.

"One of the reasons we felt the film was important right now is it's been 20 years since 'To Err Is Human' was published and patient safety has taken a back seat to other issues in healthcare, but it's paramount to the success of the healthcare system," filmmaker Mike Eisenberg told HealthLeaders.

Eisenberg said his father, who served as director of the Agency for Healthcare Research and Quality and died in 2002, was a guiding force for the documentary.

"It always came back to what my father would have wanted people to know about this issue and how he would have told this story. That guided us down the path of trying to stay positive and solutions-oriented. We wanted to show healthcare at its best rather than presenting medical error as a monster that is unbeatable," said Eisenberg, who is the director, editor, and co-producer of the documentary.

Eisenberg said three of the major themes of the film are zero-harm healthcare, maximizing the gains of patient engagement, and generating benefits from simulation.

The film, which is available on Amazon and iTunes, features interviews with three dozen healthcare leaders on patient safety issues and the heart-wrenching story of the Sheridans.

Medical catastrophe struck the Sheridans twice. First, a medical error after birth resulted in son Cal developing cerebral palsy. Second, father Pat lost his battle with cancer after a pathology report that showed a deadly malignancy languished and delayed care.

The delayed pathology report was hard for Pat Sheridan to bear, his wife said in the film. "I remember Pat crying. To think that another error had taken place—this time with him—that was difficult for us to witness."

The Sheridans' story, told by mom Sue, is interspersed between the healthcare expert interviews, which include prominent figures such as Don Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services.

Extending the documentary's reach
 

In addition to this week's general public release, To Err Is Human has been viewed at dozens of screenings at healthcare organizations, with 75 screenings held last year and 30 booked for this year so far.

"A really effective way to make change is to have a screening with a panel discussion afterward in which local or national experts talk about the film and what we can do to keep the momentum going forward. It's not enough to make a film, do a good job, and be patient," Eisenberg said.

He hopes the documentary will accelerate the drive to transform patient safety.

"This film needs to serve as a motivational tool for healthcare to keep going and keep doing better, and for patients to understand the problems so they can engage with that process."

Editor's note: This story was updated Monday, January 28, 2019, for added clarity.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


KEY TAKEAWAYS

The Institute of Medicine's groundbreaking "To Err Is Human" report was published 20 years ago.

Medical errors are estimated to claim 440,000 lives annually.

In documentary, filmmaker follows in father's footsteps.

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