Preventing Human Error in Healthcare: The Power of a “Just Culture”
Dr. Josh Williams and Emily Wood On July 2nd of 2021, two people at the University Hospital Cleveland Medical Center were undergoing surgery to receive new kidneys to save their lives. And then something went wrong. “The health system confirms a kidney meant for one patient was mistakenly transplanted into the wrong person. Now we’re told the mistake wasn’t noticed until the second operation. UH won’t confirm how far along the surgery was when the transplant team realized they had the kidney intended for the first patient. Two “caregivers" — UH would not disclose if they are doctors, nurses, or other staff —