Learning from Our Mistakes: Quality Grand Rounds, a New Case-Based Series on Medical Errors and Patient Safety

• medical errors
• physician-patient relations
• models
• educational

The case presentation has long been revered as an educational tool for physicians. Beginning early in medical school, many students eagerly devour the case presentations (often called “clinical-pathologic conferences,” or CPCs) in major medical journals, admiring both the marvelous complexity of the clinical details and the virtuoso performances of the invited discussants (1).

Over the past 20 years, the case presentation and discussion method has become more varied and nuanced. In “clinical problem-solving” exercises, cases were presented to expert discussants in “aliquots,” giving learners a chance to observe the experts' reasoning process (2). This format, as well as the incorporation of patients' and providers' perspectives into case protocols in two recent series (3, 4), has expanded the scope and utility of case presentations in medical education. These changes dovetailed nicely with a trend in many medical schools to replace lectures with case-based learning (5).

Case-based learning can be tremendously instructive and stimulating but can also carry a subtle educational threat. By emphasizing the “great case” (usually the more unusual and complex the case, the better) and the remarkable reasoning abilities of the master clinician, learners may assimilate the seductive but unrealistic message that a physician's individual knowledge and skill play the dominant role in determining patient outcomes. The patient safety corollary to this message is that poor outcomes primarily reflect deficiencies in the physician's knowledge base or cognitive and technical abilities. This unrealistic expectation of perfection undoubtedly contributes to physicians' traditional reluctance to discuss errors (6) and tends to distort these discussions when they do occur, such as in the morbidity …