Physicians need to openly discuss medical mistakes and near misses
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.
