I’ll never forget the first time I made a serious mistake in medicine.

The patient was a 54-year-old man who was on the cardiac floor after a heart attack. He had bypass surgery planned for later in the week. I was his doctor, in my second year of residency — that’s only two years out of medical school — and was in charge of ordering all his medications.

One of these was atenolol, a beta blocker usually given for high blood pressure. But we had also started him on a newer medication, Cozaar, or losartan, which had just come on the market and was good for blood pressure, but also indicated for heart attack patients.

Doctors occasionally discuss their mistakes with colleagues at conferences, but there should be  a database of such information for everyone to share. Ale Proimos/Flickr.com

I ordered both medications, and on rounds, the patient’s blood pressure went too low and he needed a quick dose of intravenous fluids to keep his pressure up. He felt a little dizzy and was fine when we put the head of his bed down a bit to help.

Within 10-15 minutes he recovered, and his pressure was back to normal, but from then on I became known as the “Cozaar Queen.” This was similar enough to my last name that some colleagues called me “Dr. Kozar” from then on.

It was a mistake, there is no other way around it. Life threatening, no. But potentially serious, had we not been there on rounds or quickly available to reverse the situation.

Medical errors are hiding in the closet and no one wants to open the door.

I had added one medication to his usual pills and didn’t consider that both medications could cause a problem if the dose wasn’t adjusted.

That’s how medical mistakes happen. Even small ones.

When researchers at John Hopkins Medical Center announced that the third-leading cause of death was medical errors, many doctors, including myself, were stunned and assumed that the statistics were skewed. Could they possibly reflect what really happens in hospitals on a daily basis?

Regardless of the accuracy of the estimates, one thing is true. Doctors make mistakes.

We are human, and hopefully we learn from those errors so that we don’t make them again. But we don’t have a systematic way to review medical errors of others and educate ourselves on how to do better next time.

Of course, I never repeated that mistake with medication after seeing the effects, and most likely, no one else on my team that day did because we all learned from the experience. But no one else knew about it.

Medical errors are hiding in the closet and no one wants to open the door.

In training, we have conferences known as “M&M,” which stands for morbidity and mortality, two unfortunate outcomes of medical mistakes. There, doctors stand in front of one another and discuss what happened, and are often chastised for it. An analysis takes place, usually by the medical doctor in charge, and blame is assessed.

But that’s where it ends. The conference is confidential, and probably always will be, given the possibility that serious errors can result in major lawsuits, or even the loss of a medical license.

There is no open forum to discuss mistakes. When something egregious goes wrong, there may be an investigation from the risk management department, but there is no public discussion of the results, and only the doctors or staff involved are informed of the final report.

Sharing all of this information among patients and family would probably just erode whatever confidence people have in the medical system, and perhaps could lead to a greater code of secrecy in fear of lawsuits, and financial repercussions.

That doesn’t meant everyone should be kept in the dark. Having a national repository of data that is accessible to doctors to review would help to share the education that everyone gets when they make a mistake, and hopefully prevent them from happening again. Rather than waiting for someone to get hurt, we could all learn from the errors of one another.

I have had the opportunity to sit on the Medical Inquiry and Conciliation Panel several times in my career, and participate in the legal process of evaluating a case to see if the plaintiff’s claim of malpractice has merit.

It’s an enlightening process, and each time I have learned a pearl of wisdom the helps my patients get better care. But there is no centralized database where I could review all the cases brought to the panel, and there should be.

People have made comparisons of the medical world to the aviation industry, where the National Transportation Safety Board and the Federal Aviation Administration carefully investigate every single plane crash on U.S. soil, and do a root-cause analysis to determine what went wrong.

The findings are shared among the pilots and the aircraft manufacturing companies to make continual improvements in the safety of the planes and the way they are flown, to keep people safe.

If every medical error resulted in a multi-year investigation, the entire medical system would come to a standstill. However, there are lessons to be learned from this careful attention to detail when things go wrong.

The functions of the human body are not as orderly as those of a plane, but the system of checklists, double-checks, reporting of problems, and public acknowledgement of areas for improvement would help the medical system, patients included.

After rounds that fateful day, having checked on my patient several times, I learned a priceless lesson about medication errors that I have never forgotten.

Just like a pilot on a plane, I have a vested interest in getting this right. My life, and those of my patients, depends on it.

No one wants to make a mistake that hurts someone, but when it happens, being brave enough to share it might just save lives.

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