When things go wrong
We are human. We all stuff up sometimes.
We try to prevent mistakes by studying, peer review, courses and listening to our colleagues – especially our patients’ guardian angels, the nurses.
But when we do make mistakes what we do afterwards to address the mistake is important. As I’ve made plenty of mistakes I’m now getting pretty good at this
So let’s look at a recent case of mine.
An 85-year-old lady with a skin tear of her shin is referred in by the wound care nurses because the wound is growing a group B strep and the wound is smelly. I’m not a great fan of wound swabs, especially in our low MRSA environment, because wound colonisation does not necessarily mean infection. An RMO / resident assessed the patient and asked me to have a look at the wound. With my bias against wound swab I went to assess the patient. Post cleaning the wound looked not too bad, it wasn’t sloughy, it didn’t smell, it had a little redness around it, it didn’t look infected but there was some dead tissue in the wound. I thought it needed debriding but not antibiotics. I debrided the wound using IV fentanyl as analgesic. The wound looked quite healthy after the debridement. I arranged for dressing and follow up next day with no antibitoics. The wound care nurse then approached me saying the woman was on immunosuppressants for her rheumatoid arthritis and needed antibiotics. I hadn’t been aware of the immunosuppresants but stubbornly persisted with my plan.
A few days later the woman returned with definite infection of the wound and ended up admitted on IV antibiotics.
In the investigation of diagnostic errors several types of errors have been described:
• Anchoring bias – locking on to a diagnosis too early and failing to adjust to new information.
• Availability bias – thinking that a similar recent presentation is happening in the present situation.
• Confirmation bias – looking for evidence to support a pre-conceived opinion, rather than looking for information to prove oneself wrong.
• Diagnosis momentum – accepting a previous diagnosis without sufficient skepticism.
• Overconfidence bias – Over-reliance on one’s own ability, intuition, and judgment.
• Premature closure – similar to “confirmation bias” but more “jumping to a conclusion”
• Search-satisfying bias – The “eureka” moment that stops all further thought.
I anchored that this leg was not infected. We do similar things with our treatment decisions: I anchored onto my treatment plan
When first informed about this turn of events, I had that sick feeling in my stomach we all know, then I got defensive and tried to justify what I had done, but slowly I accepted what I’d done was just wrong.
So what do you do when you make mistakes?
As a junior the first thing to do is to talk to a senior
a) to let them know,
b) to get some perspective on what you have done. Some times we flog ourselves when really our mistake was only a tiny factor in what went wrong, or for the more arrogant among us we may underestimate the impact of our mistakes, and
c) so they can guide your response to this mistake. Your response will be guided by your medico-legal environment. I am lucky enough to work in New Zealand where we have a system that allows and encourages early apologies.
For a more serious case you will be going through your hospital’s complaints/patient safety system and involving your medical defense organisation and will follow their advice.
Many minor cases can be addressed with an apology to the patient. Go to the ward or phone the patient at home. The approach for exams and lawyers is to express sympathy without admitting fault: “I am sorry this has happened to you. We will be investigating what happened and will let you know the outcome.” Often, however, we know that we were wrong and the best thing to do is to acknowledge this and apologise. Patients are usually incredibly generous and forgiving. They can see you are a caring human who is actually remorseful and this does a lot to make them feel better. You were not some heartless doctor who doesn’t care that she ended up with an infected leg. If the patient does not forgive you, well at least you know where you stand and you feel a little better for trying to apologise. Most of the time though, patients do accept our apologies, as this lady did, and this is a huge weight off your shoulders and you can get on with your work without the guilt hanging over you.
Write in the patient’s notes that you have apologised, or expressed your sorrow about the patients situation without acknowledging guilt, or what ever you did:
a) this an important legal record, should this case end up in court
b) it lets the inpatient team know you have made the effort to communicate with the patient and have learned from your mistake.
Also apologise to anyone else that you need to. In this case I needed to apologise to the wound care nurse.
The case went into our hospital’s incident reporting system for further investigation as required.
Last thing is to share what you have learned with your colleagues. Hopefully you have a regular departmental meeting where cases are discussed and you are encouraged to talk about cases that went wrong and what you learned from them. If you don’t have one of these meetings make one happen! It was one of my great pleasure to arrive at my current department and find they had weekly meetings in which the discussed interesting cases and lessons learned. An environment that encourages open disclosure to patients and to colleagues is wonderful to work in – and safer for patients.
Croskery. 2003 www.ncbi.nlm.nih.gov/pubmed/12915363