The Recipe for Medical Errors: This One Takes the Cake

By  |  February 7, 2009 | 

We now know that most serious medical errors – including the biggies like wrong-site surgery – stem from communication failures. But these types of failures aren’t unique to medicine. Here’s a sidesplitting one from the cake-baking business.

Thanks to John Nelson for pointing this one out to me, from the blog “Cake Wrecks.” (Yes, a blog devoted to chronicling “when professional cakes go horribly, hilariously wrong.” What did we ever do before the Web?). The story is hard to verify, but – if medical errors are any judge – I’m guessing that it’s true. Here goes:

[Answering phone] “Cakey Cake Bakery, Jill speaking! How can I help you?”

“Hi, I need to order a cake for my boss. We have a photo of him playing golf that we’d like to put on it, though – can you do that?”

“Of course! Just bring the photo in on a USB drive and we’ll print it out here.”

“Great, I’ll bring it by this afternoon.”

A while later…

“Hey, Jill, what am I putting on this cake?”

[Calling from the back room] “Oh, check the counter; I left the jump drive out for you there.”

“Really? This is what they want on the cake?”

“Yeah, the customer just brought it in.”

“Okey dokey!”

And here’s the resulting cake!!!

[The original blog post is here, accompanied by nearly 200 comments!]  

This enters my Pantheon of Screw-ups, not quite reaching the pinnacle – that position is securely occupied by the poor guy who found himself being mistakenly interviewed on live BBC television (about intellectual property law) when he showed up for a job interview. But it’s pretty good.

All these cases share similar recipes: two-parts sloppy processes mixed with one-part “it must be right” (the most dangerous words in any complex organization, by the way), often sprinkled with a few tablespoons of time pressure. It’s a recipe that is also common to most medical errors.

The difference, of course, is that their glitches wreck cakes, while ours can harm and kill people.


  1. menoalittle February 8, 2009 at 1:42 am - Reply


    Your sidesplitting post is timely as our mistaken politicians dream of and spend $billions on HIT because “it must be right”.

    The deception by Madoff was aided by just such a dangerous and epidemic illusion of computers and perfection: “it must be right” because how could his complex computer trading programs make errors.

    The computer associated illusion, “it must be right” is, indeed, the recipe for HIT perpetuated mistakes in medical care, patient privacy, and regional and national economic decisions that are happening in front of our very eyes:

    Cognition and communication are inextricably intertwined determinants of clinical judgment. IT associated deception and illusions are dangerous to our medical and financial health. Just ask the Madoff investors and the family of the victim of eight consecutive overdoses described above.

    Best regards,


  2. menoalittle February 8, 2009 at 2:02 am - Reply


    The UK National Health Service was also victimized by “it must be right”:

    Congress ought ask the Houses of Commons and Lords for clarity if it was right.

    Best regards,


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About the Author: Bob Wachter

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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