Documenting patient safety in America: 'To Err is Human' filmmaker shares his story

Before his death in 2002, John M. Eisenberg, MD, was an international patient safety expert who inspired change in the healthcare industry through his work as director of the Agency for Healthcare Research and Quality. His legacy also inspired his son — Mike Eisenberg — to direct a documentary on patient safety and medical errors, called "To Err is Human."

Mr. Eisenberg works as a full-time creative director at Tall Tale Productions, working on filmmaking and commercial work with his two business partners. Mr. Eisenberg's educational background and professional experience may not include medicine or healthcare management, but he considers this advantageous for a filmmaker: His lack of experience in healthcare allows him to research patient safety through an outsider's perspective, he says.

As part of his research, Mr. Eisenberg has spoken with dozens of healthcare leaders, including:

  • Jeff Brady, MD, director of AHRQ's Center for Quality Improvement and Patient Safety
  • Helen Burstin, MD, chief scientific officer of The National Quality Forum
  • Carolyn Clancy, MD, assistant deputy under secretary for health, safety and quality of the Veterans Health Administration
  • Nancy Foster, vice president of quality and patient safety policy of the American Hospital Association
  • Paul Goldberg, editor and publisher of The Cancer Letter
  • Richard Kronick, PhD, director of AHRQ
  • Lisa Simpson,, MB, BCh. president and CEO of AcademyHealth

The "To Err is Human" production team is planning additional interviews with healthcare leaders, hospital executives and people whose lives have been impacted by the consequences of medical errors.

Between shooting interviews and editing film, Mr. Eisenberg answered a few questions for Becker's Hospital Review about his documentary, his father's work and the state of patient safety in the healthcare industry today.

Note: Responses have been lightly edited lightly for length and clarity.

Question: Was your father's work always a big part of your life growing up or are matters of the healthcare industry more of a recent interest?

Mike Eisenberg: My father passed away when I was in high school and I admittedly did not have a personal interest in his work. At the time, I knew he was an important figure in healthcare policy, but I did not look too closely at his work. In the almost 15 years since his passing, I have learned about his work and his ability to bridge the political gaps through the anecdotes of his colleagues. I like to think of this film's production as a way of retracing his steps and presenting patient safety in a new way, while also working to understand what led him to be so passionate about his work.

Q: What made you decide to make a documentary about patient safety and medical errors?

ME: The initial inspiration came from news that AHRQ was potentially going to be defunded. I didn't understand how any political element could get rid of what I understand as an essential part of healthcare, so I looked a little closer and thought about making a documentary about AHRQ and its efforts. While that is still a significant part of our documentary, we transitioned the film's main focus into the broader story of patient safety: Where are we at today? What's changed and what hasn't? Why don't we talk about this at the national level? What does preventable harm even look like? What does it do to individuals and families physically, emotionally and financially? What can we actually do about it?

We've recently turned our focus to also include my personal journey of understanding my dad's work and why he was so passionate about it. So it will definitely take on a personal angle of my own journey to learn about patient safety.

Q: Who is the documentary's target audience? Is it for healthcare experts, lawmakers and advocates, or laypeople?

ME: The initial goal of the film is to influence the layperson to take an active role in their healthcare experience. We seek to inform the average American about what patient safety is and why it should matter to them. But in doing so, we believe that we will speak clearly to the experts and policymakers as to how they can do a better job at improving patient safety. It is not an attack on doctors and nurses, nor is it an attack on any individual. Instead it focuses on the human issues at the heart of medical errors.

Q: What is your goal in making this film? Is it to raise awareness, call for regulatory changes in the industry or provide improvement solutions?

ME: All of the above. We will present tangible solutions for patients when they arrive at the hospital and when they take their healthcare experience home with them. We will provide insight to the tech companies that are simplifying the medical process that has become too complex for even the providers to keep up with. But most importantly, we will raise awareness about patient safety and preventable harm. The fact of the matter is, most people have no idea what patient safety means, let alone what it looks like. For the most part, we can't see harm. It happens at a microscopic level. But there are a lot of things happening in front of our eyes at hospitals that can be improved on the parts of both the patient and the provider.

Q: What has been the most rewarding part of making this film so far? What has been the biggest challenge?

ME: I have to admit the most rewarding part of making this film has been tracing over my father's footsteps. I'm reading old copies of his books that he had highlighted and dog-eared. It's been quite incredible to have a professional goal that is so aligned with his career work. But on a professional level, it has been incredibly rewarding to become an active part of the patient safety movement. Like most of the general public, I've always regarded issues like patient safety to be "somebody else's issue." The reality is that someday it might impact somebody I love, if not myself directly, and through my efforts I already feel like a more empowered patient for the next time I need the healthcare system. That's the feeling I want people who watch the film to walk away with.

The biggest challenge has been raising funds for the actual production. Making a documentary is far from cheap. We've had amazing support from individuals and organizations dedicated to improving patient safety, but when it comes to the brass tax of collecting funds for the film, that's a different beast entirely. We've put an initial number at roughly $125,000 for the all-in costs of this film, but there's no way to know for sure how much more we will need once the film is completed. So far we have raised $31,000 on Kickstarter, our main fundraising effort, and $6,000 in private donations.

Q: Why did you chose to name the documentary after the landmark Institute of Medicine report "To Err is Human: Building A Safer Health System" from 1999?

ME: We did not choose the title directly because of the IOM report, but we do believe all patient safety discussions are inevitably connected to it. While there are certainly solutions presenting in the book that we feel compelled to expand upon, the fact is, in the 15 years since that report, we've lost sight of what the saying "to err is human" is really about. There are a few renditions of it. Most famously, we hear, "to err is human; to forgive, divine." We're not interested in the forgiveness version. We're interested in the original Latin proverb version, which says, "To err is human, but to persist in error is diabolical."

Our film understands that human beings will make mistakes. But why are we still making the same ones? Why is the patient-centered care such a foreign idea? Why are there not more cases like Michelle Malizzo Ballog, who died after a fatal error during surgery, and the hospital made significant policy changes as a direct result of those mistakes?

Ultimately, I think it's important to understand that our effort is not intended to solve every problem. No one documentary can. But we want to bring patient safety back into the national discussion. We want to see people understanding what it means and what it looks like. We don't want people to think that words like "healthcare" and "patient safety" and "hospital-associated infections" don't affect them. This is an epidemic. In 2000, my dad called for a "war on medical errors" and we don't have anything to show for that 15 years later.

To learn more about the documentary, watch the video below.



More articles on patient safety:
100% of investigated hospitals have cybersecurity vulnerabilities that could result in patient harm
Why Brigham and Women's Hospital put medical errors in blog form
Physician links transparency with patient safety, but overlooks adverse events at own hospital

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