To the Editor:

Thank you for your focus on errors in medical practice. We have been working on this issue locally but have found it difficult to effect change in the larger health care system. Let me share a case in point:

Recently, I read a nice article about error prevention in the physician newsletter of a large medical institution. The physician who wrote the article is now in a high managerial position, but I have known him for years to be an intelligent, reasonable and conscientious physician. In the article, he invited comments about this important issue. It so happened that the year before I had had a bad experience with this institution when it failed to report a patient’s seriously abnormal test result. I had to call to request the result after discovering through my tracking process that we had not received it after a few weeks. I offered suggestions that they tighten their tracking process but received no reply.

My colleague had put his e-mail, phone and fax numbers in the article, so I decided I would follow up with him about the problematic tracking process. I began by e-mailing him, but the e-mail did not go through. I phoned and left a message with his assistant and later a detailed message on his private voice mail with my pager number, phone number and e-mail. He did not respond. I tried to fax a letter, but it also failed to go through even after I checked the fax number with his assistant. Finally, I wrote a letter in care of the institution. I was unsuccessful in reaching him and gave up. Clearly, our health care institutions have much work to do in the area of error prevention.