TY - JOUR T1 - Ernest Amory Codman MD JF - Quality and Safety in Health Care JO - Qual Saf Health Care SP - 104 LP - 105 DO - 10.1136/qhc.11.1.104 VL - 11 IS - 1 AU - D Neuhauser Y1 - 2002/03/01 UR - http://qualitysafety.bmj.com/content/11/1/104.abstract N2 - Ernest Amory Codman MD (1869–1940) was a Boston surgeon. Like all of us he was human and made mistakes. Unlike others he made a lifelong systematic effort to follow up each of his patients years after treatment and recorded the end results of their care. He recorded diagnostic and treatment errors and linked these errors to outcome in order to make improvements. He was sufficiently disgusted with the lack of such outcomes evaluation of care at the Massachusetts General Hospital where he was on the staff that he resigned to start his own private hospital which he called the “End Result Hospital”.From 1911 to 1916 there were 337 patients discharged from Codman's hospital. He recorded 123 errors and measured the end results for all these patients. He grouped errors by type. There were errors due to lack of knowledge or skill, surgical judgment, lack of care or equipment, and lack of diagnostic skill. In addition to the errors there were four “calamities of surgery or those accidents and complications over which we have no known control. These should be acknowledged to our selves and to the public and study directed to their prevention”.The difference between Codman's hospital and your healthcare organisation is that he admitted his errors in public and in print. They are all described in the annual report of his hospital. Codman paid out of his own pocket to publish this report so that patients could judge for themselves the quality and the … ER -