title: Grading Duke: "A" for acknowledgment.
abstract: The death of seventeen-year-old heart transplant patient Jesica Santillan at Duke University Hospital due to a mismatch of blood types sent shockwaves across the country and brought heightened attention to the issue of medical error. This Article explores the modern literature on medical error and proposes changes in medical culture to effectuate a system in which medical errors can be reported without fear. It argues that the way to achieve this goal is by placing less focus on the individual and more on systemic factors that provide the conditions in which errors occur. This new system would take a proactive approach to error, change the culture of medicine, and relieve physicians of the burden of impossible overachievement.
authors.forename: Amie
authors.initials: A
authors.lastname: Sloane
mesh_terms: D000293:Adolescent; D001788:Blood Grouping and Crossmatching / Q000592:standards; D005260:Female; D016027:Heart Transplantation / Q000009:adverse effects / Q000592:standards*; D006785:Hospitals, University / Q000592:standards*; D006801:Humans; D016365:Liability, Legal; D019300:Medical Errors / Q000517:prevention & control; D015969:National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division; D009657:North Carolina; D015279:Organizational Culture; D017751:Safety Management; D013597:Systems Analysis; D009927:Tissue and Organ Procurement / Q000592:standards*; D014342:Truth Disclosure; D014481:United States