What Causes Medical Errors?

October 14, 2020


Mary Greeley Medical Center Grand Rounds is a multi-disciplinary clinical activity which serves to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public or the profession.

Target Audience

Physicians, Advance Practice Professionals, Nurses, Ancillary Staff, Medical Students (Rotating), Non-Medical Students (Rotating), and Healthcare Administrators.

Educational need

Error analysis is one of the most powerful and effective strategies for a "learning health system." Not enough time and attention is given to capturing, reviewing, and exploiting the safety benefits of errors in most healthcare organizations. Errors should be treated the same way as pathology reports. To improve the process, many "quality improvement" programs still have roots in a medieval culture of "shame and blame," which is antithetical to a "culture of safety." Error research still relies on cumbersome and most inadequate "tabulation" of incident reports that do not often create actionable lessons. 

Learning Objectives

  • Share storied of "thing that went wrong" and "near misses" among professional peers and benefits from their educational value.
  • State "root cause analysis" is an imperfect framework for understanding error pathways.
  • Appreciate the scope and limits of errors theories, such as "cognitive bias."


Michael Victoroff, MD

Dr. Victoroff is currently a Risk Management Consultant at COPIC and President of Lynxcare, Inc. He is also a Clinical Professor at U.C. School of Medicine and an NRA firearms instructor. Previous, Michael worked in private practice (Family Medicine & OB) for 19 years. He was the 1996 Colorado Family Physician of the Year, Medical Director for Aetna, private investigator (forensic toxicology), and EHR developer. Michael has numerous publications in bioethics, public policy, health information technology, and patient safety.




  • The speaker(s) indicate they have no financial conflicts with commercial interest companies to disclose relevant to the content of this educational activity.

CME Committee

  • No member of the Mary Greeley Medical Center CME Committee who planned this activity has any financial relationship to disclose relating to the content. 

This program is supported by gifts to the Mary Greeley Medical Center Foundation from Mary Greeley Medical Center, McFarland Clinic, Availa Bank, and Green Hills Health Care Center. The content and selection of speaker(s) is the responsibility of the Mary Greeley Medical Center for Continuing Medical Education Committee and not the sponsors of this program.

    Course summary
    Available credit: 
    • 1.00 AOA Category 1­B
    Course opens: 
    Course expires: 
    Event starts: 
    10/14/2020 - 12:00pm CDT
    Event ends: 
    10/14/2020 - 1:00pm CDT

    Accreditation Statements

    • DO: Des Moines University (DMU) is accredited by the American Osteopathic Association to provide osteopathic continuing medical education for physicians. DMU designates this program for a maximum of 1.0 AOA Category 1-B credits and will report CME and specialty credits commensurate with the extent of the physician’s participation in this activity.


    No commercial interest company provided financial support for this continuing education activity.


    Everyone in a position to control the content of this educational activity will disclose to the CME provider and to attendees all relevant financial relationships with any commercial interest. The speaker(s) will disclose if any pharmaceuticals or medical procedures and devices discussed are investigational or unapproved for use by the U.S. Food and Drug Administration (FDA). Determination of educational content and the selection of speakers is the responsibility of the activity director. Firms providing financial support did not have input in these areas.


    The information provided at this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition. The content of each presentation does not necessarily reflect the views of Des Moines University.

    Available Credit

    • 1.00 AOA Category 1­B


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