I made a mistake this past week. It worked out all right – I fully informed the patient, and she’s fine. (I’m okay too; thanks for asking.) This mistake was unusual because I realized it when it happened. As a fallible human being, I make mistakes all the time, and most of the time I don’t realize it.

Sure, our system is paying more and more attention to mistakes, but most of the spotlight is focused on “errors,” a term which implies a systematic failure. A lab result goes unreported, or reported to the wrong person; a medication list isn’t checked correctly; a procedure is done in the wrong way.

We internists, however, like to think – and perhaps this is mistaken too? – that our job depends on individual cognition as well. Without our vaunted brains, the diagnosis isn’t made, the risks and benefits of treatment aren’t hashed out, or the patient isn’t cared for with attention and compassion.

What are the systems we can put in place to guarantee optimal performance at the individual level? Can we make quality improvement happen inside our own brains? For that to happen, wouldn’t we have to realize whenever we made mistkaes? And how often is that going to be the case?

I mean, mistakes.