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While it is true all doctors make mistakes, it is equally
true that most of us refuse to discuss them. Medical
mistakes have always been shrouded in a conspiracy of
silence through the ages, and this was because it was
important to give patients the impression that doctors
were infallible . Such a strategy may have been appropriate
in the past, when doctors had few effective tools in
their therapeutic armamentarium, and trust in the doctor
was a vital element of the healing process. This is
why blind faith in the doctor was encouraged , and to
keep the doctor on his pedestal, it was essential that
he have an aura of infallibility around him.
Given the prevalence of errors in our work, and that
one of our first principles is "first do no harm,"
it is strange that we talk so little about this problem.
Perhaps it is because we view most errors as human errors
and attribute them to laziness, inattention, or incompetence
As a result, when we do talk about errors, we seek to
place blame, because deep down we believe that individual
diligence should prevent errors, and so the very existence
of error damages our professional self-image.
We must realize that all of us pay a heavy price for
trying to cover up medical mistakes.
Since we often prefer ignoring, overlooking or covering
up our mistakes, we fail to acknowledge them, so
we never learn from them – and many experienced
doctors end up repeatedly making the same mistakes
through their lifetime. Also, since we don’t
discuss our mistakes, we deprive other doctors of
the chance to learn from them We know that we can
learn a lot from mistakes – often knowing
what not to do is more valuable than knowing what
to do !
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The human cost of medical errors is high. Not only do
our patients pay the price of our mistakes ( complications,
iatrogenic injury and even death); so do we when we
don’t talk about our mistakes. Hiding mistakes
means we end up carrying a burden of guilt and shame
– which can become overpowering with time, especially
when compounded by the fact that we often need to lie
to hide and cover up our mistakes.
All of us know what it feels like to make a bad mistake.
You feel exposed – and scared in case anyone else
has noticed your goof-up. You agonise about what to
do, whether to tell anyone, and what to say. Later,
the event replays itself over and over in your mind.
You question your competence , but fear being discovered.
You know you should confess, but dread the prospect
of potential punishment and of the patient's anger.
Making a mistake can be forgiven – but not
taking action to prevent it again is unforgivable,
which is why we need to be open about them. Part
of the problem lies with our medical training ,
which focuses only on teaching residents how to
fix problems successfully. When medical students
and junior doctors make mistakes, they are often
scolded, ridiculed or punished, which means that
we end up being terrified of making mistakes, and
often try to do our best to cover them up. This
attitude needs to change, and we need to realize
that mistakes are an integral part of every learning
experience. It is important to provide a structured
environment in which these mistakes can be safely
made, so patients are not harmed, and there are
many ways of doing so safely ( for example, providing
effective supervision by countersigning a student’s
medical orders; and using animal models to teach
surgical skills).
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Learning and mistakes go hand in hand, and since all
doctors need to be lifelong learners, we will all make
mistakes throughout our lives. All humans make mistakes,
and doctors are no exception. However, medical errors
are far more complex than those which occur in other
fields. As Hilfiker put it so eloquently, “ The
drastic human consequences of medical mistakes; the
repeated opportunities to make them; the uncertainty
about our own culpability when results are poor, and
the medical and societal denial about mistakes results
in an intolerable paradox for the physician. We see
the horror of our own mistakes, yet we are given no
permission to deal with their enormous emotional impact
.” This is why we often overreact to the mistakes
we make. Most doctors are perfectionists, who pride
themselves on their professional skills and competence
– and they feel uncomfortable when these are threatened.
The fact that our patients pay a heavy price for our
mistakes makes it difficult to live with the knowledge
that a patient who trusted you and placed his life in
your hands may end up losing it because of your fallibility.
After making a mistake, physicians’ emotional
reactions include: panic, guilt, embarrassment, humiliation,
and feelings of inadequacy and isolation. The ability
to acknowledge an error is the first and most critical
step in the physician's healing process, but this is
often hard to do. Many physicians typically respond
to their mistakes defensively, by blaming the system,
other members of the health care team, or even the patient.
Other unhealthy coping mechanisms are denial of responsibility
(“it's a bad system”), discounting of importance
(“it had no significant clinical effect”),
and emotional distancing (“everyone makes mistakes”).
Our profession is difficult enough without our having
to bear the yoke of perfection. The most effective
way for physicians to cope with their emotional
reactions after making an error is to discuss such
feelings with trusted friends, colleagues or a spouse.
However, medical culture ( partly because of the
fear of malpractice litigation) encourages cover-ups
of mistakes, because of which most physicians bear
the burden of their mistakes in isolation.
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When an error occurs, most patients would like to be
informed about this error; and they naturally expect
the doctor to provide an explanation or an apology,
and to rectify the error , and this is what the doctor's
ethical obligation to the patient is. However, given
the fear of a malpractice lawsuit being slapped on them,
most doctors today still react to errors by trying to
cover them up and hiding them from the patient. This
often makes a bad situation worse. Most patients who
finally end up pursuing litigation usually have multiple
complaints including (1) professional failure in diagnosis
or treatment, (2) a lack of communication on the part
of the doctor; and (3) some form of insensitivity on
the part of the doctor that has emotionally upset them.
This sorry state of affairs implies that insult has
been added to injury. Such a development not only destroys
the relationship of trust between doctor and patient
but it also makes the patient more vengeful if he does
find out about the medical botch-up through another
source. In the final analysis, remember the Golden Rule
- do unto others as you would have them do unto you
! Try to look at things from the patient's point of
view. All said and done, honesty is still the best policy
When colleagues or employees make mistakes , please
be charitable – it may be your turn to err
tomorrow. Don’t lose your temper, or make
fun of them. Instead, try to help to correct the
mistake; and teach them to learn from their error,
so they are more confident for the future. When
your junior or colleague makes an error, encourage
a description of what happened; acknowledge the
gravity of the mistake; and empathise with the emotions
it elicits before embarking on a more objective
analysis. A good response would be: “ I am
glad you are willing to discuss this error openly.
This reflects your intellectual honesty and compassion,
both of which are attributes of a good doctor. I
know you feel terrible: this is normal. Let’s
sit down and review the case. Now, if you had it
to do over, what could be done differently?"
The right response to mistakes is to use them as
teaching tools, so we learn from them, and don’t
repeat them.
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To prevent mistakes, you need to be aware of the settings
where mistakes are more liable to occur – and
be even more careful during these high-risk times to
prevent problems . Circumstances which increase scope
for error include: times you are tired, lazy, or overconfident;
late at night, when you are sleepy ; when you are angry;
when the patient is irritating ; or when the patient
has a complex medical problem .
It’s important to take a proactive approach towards
preventing mistakes, and you need to work on developing
systems, policies and protocols to prevent mishaps.
For example, instead of relying on memory, use preprinted
forms. A good example is the use of preprinted order
forms for post-operative orders, which simply need to
be ticked and signed. Flowcharts and algorithms can
be helpful to prevent diagnostic errors; and personal
digital assistants can serve as peripheral brains, since
they can be equipped with extensive drug and clinical
databases.
The Institute of Medicine report, To Err Is Human:
Building a Safer Health System, which was released
in December 1999 in the US, focused the glare of
public attention on medical mistakes. Its most important
insight was that most errors result from faulty
systems, not from incompetent providers, and it
is these systems that need to be revamped to anticipate
human error and catch it before it harms the patient.
Unfortunately, when something goes wrong in a hospital,
the press looks for victims and villains , and ends
up blaming doctors unfairly.
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Errors are not unique to healthcare. Other industries
already realize that it is faults in the system which
permit humans to err, and they have designed changes
in the system itself to minimize errors. The aviation
industry is renowned for designing a system to minimize
the chance of errors, by relying heavily on research,
on reporting of errors and near-misses to identify potential
problem areas, and on designing redundancy into the
system so errors are caught before they become disasters.
When errors occur, we should learn and prevent,
rather than blame and hide. Reporting of errors
is essential – and it is important that we
allow it to be done voluntarily and anonymously,
so doctors ( and other staff) do not feel threatened
when they report errors. After gathering data about
adverse events or near misses , we than need to
analyse them. A structured approach to analysing
critical incidents allows us to systematically examine
systems and processes rather than fall back on habitual
blaming behaviors and biases. This technique is
called root cause analysis (RCA) and is widely applied
to investigating industrial accidents today. Many
studies have shown that errors are not the result
of a single incident. Rather, they occur as a result
of a chain of events ( latent errors), which when
compounded together lead to the active error.
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Allowing patients to become active partners in their
medical care is effective in reducing mistakes. Encourage
your patients to seek more information and to become
an expert on their own problem. Any one doctor or nurse
can make a mistake, but the well-informed patient can
prevent such errors, by acting as his own last line
of defence. You may forget and make mistakes, but a
well-informed patient will not allow you to get away
with them !
BOX – Dealing with mistakes
1.Accept responsibility for the mistake
2.Discuss it with colleagues
3. Disclose and apologise to the patient
4. Conduct an error analysis
5. Make changes in your practice to reduce similar errors
in the future
The best way to put this advice into practice is to
think about the last mistake you made that harmed
a patient. Talk to a colleague about it. Notice
his reactions, and your own. What helps? What
makes it harder? Physicians will always make mistakes
– but how we handle them is upto us. The
best way is by being more honest about our mistakes
to our patients, our colleagues, and ourselves.
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