The Surgical Mistake and the Bad Decision That Followed: Dr. David Mayer

The Surgical Mistake and the Bad Decision That Followed: Dr. David Mayer


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My guest for Episode #70 of the My Favorite Mistake podcast is Dr. David B. Mayer. He is both the Chief Executive Officer of the Patient Safety Movement Foundation and Executive Director of MedStar Institute for Quality and Safety.

In today's episode, Dave shares a compelling story from his time as an anesthesia resident. What happened after the surgeon cut into the wrong side of the patient? Was the coverup worse than the crime? What did Dave learn from this incident and the pressure to keep quiet? How has this inspired him to be a patient safety leader?

Questions and topics include:

  • Lectures now about how to respond to harm… how do the students react?
  • The book Wall of Silence about the harm caused by medical errors
  • Patients want the truth – parallels to the Garrison Brothers episode
  • CANDOR program
  • How do mistakes like this happen?
  • Culture? Feeling safe to speak up? Can’t just demand candor?
  • Just Culture
  • His ZERO hat — How many patients are harmed or killed by preventable medical error each year?
  • Moon Shot?” Video
  • What would you do if you were made Patient Safety Czar?
    • 1) Committee to talk about the moon shot 
    • 2) National patient safety authority like NHTSA or aviation
    • 3) Incentives better aligned around patient safety & quality
    • 4) Transparency 

Scroll down to find:

You can listen to or watch the episode below. A transcript also follows lower on this page. Please subscribe, rate, and review via Apple Podcasts or Podchaser! You can now sign up to get new episodes via email, to make sure you don't miss an episode. This podcast is part of the Lean Communicators network.

Watch the Episode:


"It was horrifying to all of us. I never been involved in a mistake, a medical error that had harmed a patient."
"When we hide errors like that, when we bury them within our own little silos, we don't learn."
"The mistake that I've lived with for 35 years has shaped my career in many ways."

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Automated Transcript (Likely Contains Mistakes)

Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. His latest book is Measures of Success: React Less, Lead Better, Improve More. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. He also published the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus. He is also a Senior Advisor and Director of Strategic Marketing with the healthcare advisory firm, Value Capture.