Next to the promulgation of the truth, the best thing I can conceive that a man can do is the public recantation of an error.Lord Lister

While it is true that all doctors make mistakes, it is equally true that most of us refuse to admit to or 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 one of our first principles being “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 ones 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.

Learning from our mistakes

We must realize that all of us pay a heavy price for trying to cover up medical mistakes. Since we often prefer to ignore, overlook or cover up our mistakes, we fail to acknowledge them, and so we never learn from them; 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 can learn a lot from mistakes–often knowing what not to do is more valuable than knowing what to do!

The human cost of medical errors is high. Not only do our patients pay the price of our mistakes in the form of unnecessary complications, iatrogenic injury and even death, but 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 agonize about what to do, whether to tell anyone, and what to say or not 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 are afraid of having to bear the brunt 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 expects residents to be perfect. 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. There are many ways of doing so safely (for example, providing effective supervision by countersigning a student’s medical orders; and using animal models or virtual simulators to teach surgical skills).

The paradox

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 so eloquently put it- “ 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.”

On the defensive

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, the physicians’ initial emotional reactions include panic, guilt, embarrassment, and humiliation. 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 justify their mistakes by becoming defensive. They will :

* Blame the system; blame other members of the health care team; and even blame the patient

* Discount its importance by claiming “it has no significant clinical effect”

* Exhibit emotional distancing by rationalizing that “everyone makes mistakes”

Our profession is difficult enough without us 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.

Why the cover-up?

When an error occurs, most patients would like to be informed about this error. 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:

* Professional failure in diagnosis or treatment

* Lack of communication on the part of the doctor

* 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! All said and done, honesty is still the best policy.

When colleagues or employees make mistakes, please be charitable towards them–it may be your turn to err tomorrow. Even if you are upset, please don’t exhibit your anger and shout at them. It’s very tempting to belittle them or go on a witch-hunt to pin the blame on them at this time, when emotions are running high, but how well you handle this difficult situation will define your maturity. It’s very easy to berate them for their mistake, but this will just make a bad situation worse.

The perpetrator of the error is already beating up on himself, so there’s no point in adding to his angst. Instead, try to help to correct the mistake; and help them learn from their error, so they are better prepared to handle similar situations in the future. When your junior or colleague makes an error, encourage a description of what happened; acknowledge the gravity of the mistake; and empathize 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 this all over again, what could be done differently?”

Preventing errors

The right response to mistakes is to use them as teaching tools, so we learn from them, and don’t repeat them. To prevent mistakes, you need to be aware of the settings where mistakes are more likely to occur–and be even more careful during these high-risk situations to prevent problems. Circumstances that increase scope for error include:

* Times when you are tired, lazy or overconfident

* When it is late at night and you are sleepy

* When you are angry

* When you are dealing with an irritating patient

* 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 standardized forms for post-operative orders. These simply need to be ticked and signed. They promote accurate communication; reduce variation by combining pertinent reminders, safety alerts, and evidence-based best practices; and spare doctors the clerical burden of having to repeatedly write the same orders.

* Flowcharts and algorithms can be helpful to prevent diagnostic errors.

* Personal digital assistants can serve as peripheral brains, since they can be equipped with

extensive drug and clinical databases. When errors occur, we should learn from them so we can prevent them in the future , rather than blame and hide. Reporting of errors is essential and we should allow it to be done

voluntarily and anonymously, so doctors (and other staff) do not feel threatened when they report errors.

A structured approach to analyzing errors and near misses allows us to systematically examine systems and processes , rather than fall back on habitual blaming behaviors and biases. Root cause analysis (RCA) is a useful tool, and shows that errors are not the result of a single incident, but occur as a result of a chain of events (latent errors), which when compounded together lead to the active error.

Ishikawa cause and effect diagram for analyzing why a wrong medication was given to a patient

A cause-and-effect diagram (Ishikawa diagram) can be used to identify specific factors that might have contributed to the adverse outcome in a particular case. These factors are assigned to one of six broad categories:

* Environment

* Equipment

* Leadership

* Communication

* People

* Procedures

Factors contributing to adverse events include:

* Poor communication- e.g., inadequate handoffs; incomplete clinical information

* Failure to coordinate care- e.g., involving different specialists

* Excessive workload

* Failure to escalate care-e.g., delay or failure to involve a more senior physician or nurse

* Failure to recognize change in clinical status- e.g., delay in recognizing changing clinical signs and symptoms

An effective way (which is also free!) to reduce errors is to encourage patients to become active partners in their medical care. Help 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 final line of defense. You may forget and make mistakes, but a well-informed patient will not allow you to do so!

Dealing with mistakes

1. Accept responsibility for the mistake. Take ownership of the

problem – the buck stops with you!

2. Discuss it with colleagues

3. Disclose and apologize to the patient

4. Conduct an error analysis

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 to be more hon