Medical errors

Physicians need to openly discuss medical mistakes and near misses

Sara Scarlet

Like many surgical problems, compartment syndrome must be recognized rapidly. Failing to do so may lead to a patient’s losing function in a limb, losing the limb altogether, and, in extreme cases, dying. A physician-in-training I work with missed it. Her error made me realize that medicine is suffering from its own largely unrecognized compartment syndrome.

Late one night, an emergency physician at an outside hospital called the attending physician on my hospital’s burn surgery service about a patient whose arm had been badly burned. After a brief discussion, they agreed to transfer the patient to our hospital. The trainee admitted the patient to the hospital.

Somehow, the emergency medicine physician, the burn surgeon on call, the nurses, and the trainee all missed the harbingers of compartment syndrome — the tight burned skin, the fixed deformity of the hand, and the severe pain the patient was experiencing. This dangerous condition occurs when pressure inside a confined body space builds up as a result of internal bleeding or swelling. The increase in pressure prevents blood from flowing to the area. If compartment syndrome isn’t detected in time and treated, the limb can become permanently damaged, or may even need to be amputated.

Failing to recognize the urgency of the situation, the trainee didn’t wake me to discuss the case. Instead, she waited until the day team arrived to discuss the patient. That meant her condition went unrecognized for several hours and her care was significantly delayed.

I learned about the case that morning. Devastated by the number of clinicians who had missed the warning signs, I imagined the patient lying in her hospital bed with agonizing pain in her arm as it was starved of oxygen.

Fortunately, she escaped permanent damage and eventually left the hospital with normal function in her arm — what we in medicine call a “near miss.”

The next time the trainee was working in the hospital, I sent her a page to call me so we could debrief.

Her voice cracked nervously as she said hello. We exchanged the usual pleasantries. Her next words came as a shock. “Are you calling to yell at me?”

“No,” I said, “we need to talk about how we can all do better next time.”

We discussed the details of the case and reviewed compartment syndrome. I thought the conversation was going well. But then the intern surprised me by asking, “Am I going to get fired?”

That fearful question echoed the hidden curriculum of punitive responses to error that pervades the culture of medicine. It’s especially strong in surgery, where we tend to work apart from peers. With that isolation, it is easy to assume that others are somehow infallible, and that our personal errors are egregiously unique.

We must all recognize that putting an end to our silent solidarity about errors will empower us to provide better care.

What many trainees fail to recognize early in their careers is that errors usually aren’t the fault of a single clinician. Instead, they represent the failure of a much larger system of defenses, barriers, and safeguards. In the case of our patient with compartment syndrome, the error was on behalf of the entire medical team.

I shared with the trainee a story of a mistake of mine two years earlier but still vivid in my mind. A patient of mine developed critical limb ischemia — a rapid reduction in blood flow to one of her legs. In order to properly treat her, we planned to perform an angiogram, a procedure to look at the arteries in her leg. I gave her a dose of heparin to prevent her blood from clotting without taking the time to check the results of her previous blood tests. Had I looked, I would have seen that she had been given a dose of heparin the previous day. The extra dose I administered triggered a stroke. I felt extremely responsible for it, and did not leave her bedside for hours to make sure she received the appropriate care.

The next day, the patient thanked me for “my compassion,” her words hanging in the air in the busy intensive care unit. I had never felt so ashamed. Now I recognized the same painful feelings in my young colleague.

Most doctors vividly recall their “cases of regret.” These events undeniably shape our practice. As French surgeon René Leriche wrote in 1951, “Every surgeon carries about him a little cemetery, in which from time to time he goes to pray, a cemetery of bitterness and regret, of which he seeks the reason for certain of his failures.”

Most of these regrets are quite private. As Dr. Danielle Ofri reflected in her essay “My Near Miss” on her experiences with errors, “the instinct for most medical professionals is to keep these shameful mistakes to ourselves.” They do this in part to protect themselves. According to the 2013 National Healthcare Quality Report, most health care workers believe that mistakes will be held against them.

Like compartment syndrome, failing to openly discuss errors carries with it the deep, unrelenting pain of guilt, humiliation, and shame. Left unaddressed, these powerful emotions are damaging to our professional and personal lives. In addition, failure to openly acknowledge personal experiences with errors and near misses contributes to a culture of stigma. This kind of avoidance led my colleague to believe that she was the only trainee who had made a mistake, which instilled in her a deep sense of regret and shame.

Keeping medical mistakes in the shadows is bad for individual clinicians and for the medical system, since we can all learn from mistakes. So how do we discuss them with the people who support and mentor us as we navigate through training and beyond? More specifically, how do we communicate how our mistakes make us feel?

We often discuss the appropriate ways to disclose errors to patients: apologize, be honest, and accept responsibility for one’s mistakes. But the medical culture fails to provide an effective platform for us to discuss errors with one another on a more personal level.

Creating a safe environment for discussing errors will help future physicians succeed where others have failed. It will help improve our health care systems, create a culture of safety, and work to eliminate the damaging culture of stigma.

The standard morbidity and mortality (M&M) conference is supposed to offer clinicians a public forum for presenting medical errors and complications. But these tend to cultivate an atmosphere of detachment — trainees impersonally convey details with an attitude of indifference. The M&M conference generally doesn’t offer the opportunity for discussing what lies deeper.

Debriefing represents an excellent step forward. The purpose of this exercise is to discuss the actions and thought processes surrounding a specific patient care situation, to reflect on them, and to incorporate improvement into future performance. The debrief can be an effective forum for addressing the personal toll of experiencing a serious event.

But I’ve found that in the absence of a sentinel event — an unexpected death or serious injury — debriefing is rare. When the dust settles after an error is made or a patient experiences a complication, we often scurry back to our tasks and deal with the psychological aftershocks alone.

Vulnerability is an integral aspect of leadership, something that all physicians should acknowledge. With vulnerability comes strength. From the novice trainee to the most seasoned surgeon, we must all recognize that putting an end to our silent solidarity about errors will empower us to provide better care for our patients, for each other, and for ourselves.

The nature of our practice and the fact that we are human beings means that we will make mistakes. Bad doctors aren’t the only doctors who make errors; rather, they are the ones who refuse to learn from their mistakes. As many of us in surgery say, “The enemy of good is perfect.”

Sara Scarlet, M.D., is a general surgery resident at the University of North Carolina.