I picked-up a copy of Internal Bleeding, a book about medical errors, in my quest to better understand the work I have in the healthcare business relating to quality and safety. It primarily lists a lot of cases where errors are a result of poor hand-offs where often everyone assumes someone else must have checked something critical because it was so critical that they generally never need to check it by the time it reaches them. Mistakes resulting from such things include wrong side surgeries like an amputation of the left leg when the right leg needed to be amputated or doing a heart, a lung transplant on a seventeen year old where the blood type doesn't match, and delivering a toxic dose of chemotherapy because the prescription was misunderstood There are systems in place for fixing such issues but they primarily don't get fixed through data warehousing. We could detect whether they happened and suggest that the system be enhanced before something bigger and worse than small errors occurred.

The book has in it a lot of other interesting information in it. For example - someone did a study where they looked at how people evaluate decisions based on risk. People would rather take on additional risk against a loss than risk on a gain. So if someone is given a choice where they will either get $40,000 in cash or take a coin flip for $100,000 or nothing most people would take the $40,000. If they were presented the opposite situation where they could either owe $40,000 or flip a coin and owe either $100,000 or nothing they would take the coin flip. In both cases they are wrong in their choice because the expected value in the first case from their decision would be to trade-off $40,000 for $50,000 and in the second case they would trade a debt of $40,000 for an expected debt of $50,000. This leads people predictably to gamble on long-shot horses more often at the end of the racing day than at the beginning. (One thought I had was to test this by checking on whether the "favored" horses pay better at the end of the day... and to see if there is a way to leverage this in capital markets).

Plenty of other great information in the book about how medicine is practiced, why the system is broken, and tips to fix it. It is very readable focusing on real examples so I recommend it highly even for people not interested in patient safety and quality healthcare initiatives.