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Chapter 24: Managing mistakes in medicine – what to do when you err
| "We are built to make mistakes, coded for error." - Dr Lewis Thomas. |
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 ! TOP 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 patients 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). TOP 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 physicians 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 ("its 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. TOP 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 doctors 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 patients 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. TOP 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. TOP 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. TOP 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 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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