Don Berwick: To Err is Human

“I was human the night I almost killed a baby.”

“I was human the night I almost killed a baby,” Don Berwick said plainly to a crowded room of South Carolina hospital employees. And while it’s the type of comment that makes health care professionals squirm in their seats, it also demonstrates the courage needed to take on an industry averse to change.
Today, Berwick travels the country bravely sharing his mistake with the hope that it will eliminate similar errors in the future.

It was 3 a.m. in the neonatal intensive-care unit when Don Berwick administered the wrong medication to an infant, almost taking a life, and changing the course of his own for years to come. As he sat alone in a room after the incident and cried, a fellow physician comforted him. “It could have been anyone Don,” his colleague said. After questioning himself as a physician, and as a human, he realized that it really could happen to anyone, and the only way to prevent it from happening again was to implement a better system.

Dr. Berwick has seen health care from many perspectives, from fresh-faced pediatrician to head of the Centers for Medicare and Medicaid Services (CMS). He understands the need to lower costs in health care; he just believes we’re going about it the wrong way by focusing on cost rather than quality. That was his message to attendees of his session at SCHA’s Transforming Health Symposium at the Columbia Convention Center.

He explained that as long as we’re human, there will be errors. However, if we can build highly reliable systems that mirror those used in other hazardous industries like nuclear power and manufacturing, we can improve quality and eliminate unnecessary medical errors that drive up health care costs. Put simply, rather than focus on removing cost, focus on improving care and the benefits will be greater.

Berwick challenged attendees to break from specific projects and measures that can be burdensome and to focus on fully transforming the health of the communities they serve. “We will never inspect our way to excellence. We can only improve to excellence,” he said.

Berwick has worn many hats in his health care career, with the latest being that of a health care transformer. As president emeritus and senior fellow at the Institute for Healthcare Improvement (IHI), he travels the country inspiring health care providers to focus on system redesign and quality rather than the bottom line. He noted that among the states he has traveled to, South Carolina is one that he is keeping his eye on. He recognized several individual hospitals as well as the state for being a national leader in improving the quality and safety of care for patients.

“Can South Carolina be the place where the Triple Aim is made real?” he asked. Quickly responding to his own question, “I don’t know what it is, but there’s something in the water. Drink it.”