Dealing
with Mistakes
(see
related PowerPoint
presentation)
MAJ
Brian C. Harrington, MC, USA
Faculty
Developmant Fellowship
Madigan
Army Medical Center
(Edited
for web page 21 July 1999)
All providers make mistakes in the practice of medicine. One well-publicized study found that iatrogenic events occurred in 3.7% of admissions in the state of New York[1]. Other studies have suggested that iatrogenic events might occur in as many as 36% of patients admitted to hospitals[2, 3]. While society and our medical system focus mistakes, individual providers infrequently have permission to discuss their mistakes and associated feelings. Family physicians, who see the broadest array of patients and medical conditions, perhaps have the greatest daily potential for making mistakes.
How do providers respond to making a mistake that can harm a patient? Do we tell the patient or colleagues? Do we tell anyone? How do we feel? How does it affect our future practice of medicine? One survey of residents found that 88% discussed a mistake with another physician and 54% discussed it with their attending[4]. Only 24% discussed it with the patient and 5% discussed it with no one.
Several beliefs influence how providers respond to making a mistake. First, physicians have traditionally been placed upon a pedestal as perfect and infallible[5]. The current emphasis on high technology and the belief that American medicine can do anything also contribute to an expectation of perfection. Error thus implies negligence. The threat of malpractice is related to this expectation of perfect outcomes.
Issues of control are a second influence. We are trained to control the human body and its physiological processes. Physicians usually occupy positions of control in our health care system. Some providers may become "control freaks" in order to reduce the uncertainty inherent to medicine[6]. Admitting to a mistake can be interpreted as an admission of not being in control.
A third belief is the perception that making a mistake signifies a character flaw. You must be a "bad" physician if you make a mistake. Our medical schools and residency programs contribute to this. Teachers of medicine are often presented as "experts" and perfect practitioners of medicine. Intense competition is a hallmark of our pre-medical and medical training. Medical students and residents are compared with their peers and evaluated for competency. The medical training environment fosters a culture where the admission of mistakes is seen to reflect poorly upon the person committing the mistake, and often carries negative consequences. The fear of ridicule and reprimand has an unhealthy influence on how we respond to making a mistake.
Fourth, feelings and actions can be influenced by the likelihood that the given mistake could be expected to occur. Missing a displaced fracture on an x-ray might bring up intense feelings, while missing a hairline fracture on an x-ray may not be so traumatizing because "those are sometimes tough to pick up." Finally, making a mistake affects our global self-assessment of confidence. Feelings of incompetence can lead to increasing guilt and remorse. For most of us making a mistake brings up predictable emotional reactions. A survey of family physician staff reported that after making a mistake 81% felt remorse, 79% felt anger, 725 felt grief, and 60% acquired feelings of inadequacy and self doubt[7]. Agony and anguish are also common[8].
The feelings aroused and the disinclination to discuss mistakes can result in unhealthy coping mechanisms. Some providers develop a "God complex" where they will harbor no questioning of their judgement and actions. They are always right. Others might act overly defensive, even at the slightest suggestion they might have erred. Another ill reaction is to blame others and not accept responsibility. Most providers have witnessed colleagues acting out, yelling, and being passive aggressive. Finally, and perhaps most dangerously, some providers turn to alcohol and drugs to deal with their emotions.
If dealing with our mistakes can be so bad, why should we even do so in the first place? Several reasons compel us to accept responsibility for our mistakes and to discuss them. First, we are ethically bound to tell our patients when we have made a mistake. Patients have a right to know what is being done to them. This was reaffirmed by the Nuremberg Codes of 1947[9]. Also, if a provider makes a mistake, the patient has a right to know so they can switch to a provider whom they more trust.
It is paternalistic to say that we should not tell a patient because it might upset them, or that the mistake did not hurt them anyway. Patients want to know if mistakes are made. A study done in 1996 at Loma Linda University asked patients at an internal medicine clinic how they would respond to a given set of mistake scenarios when informed of the mistake as compared to not being informed[10]. Respondents were LESS likely to sue if informed of the mistake, and 98% wanted know when any mistakes are committed. Other studies have also indicated that communicating with patients reduces the risk for lawsuits[11, 12].
The welfare of future patients also compels us to discuss our mistakes. Most mistakes can be categorized in four areas: physician stressors like the lack of sleep; process of care factors such as job overload; patient characteristics and complexity; and physician characteristics such as experience[13]. These are inherently system problems requiring system solutions. Providers should learn from each other's mistakes. If the system is not made aware of problems it is hard to correct them. Thus discussing mistakes may improve the system, which benefits all providers and in turn all patients. However, one may need to consider legal ramifications when choosing the venue for discussion and when documenting mistakes.
Discussing our mistakes is ultimately helpful to the provider making the mistake. Disclosure reduces stress. Talk about how you feel about a mistake. Sometimes we might even benefit from a good cry. One caveat: this requires all of us also to be good listeners. Be empathic and supportive. Discussing a mistake can also be spiritually uplifting as a sort of confession. We all seek absolution and acceptance. Be giving of it.
Finally, I believe that the state of our medical culture demands that we make changes. If providers routinely talked about their mistakes, then making a mistake and talking about it could become a benign experience. Discussing mistakes should be a casual, everyday experience rather than an oddity laced with apprehension and fear. We need to encourage this change at the earliest stages of the medical training process. Teaching staff need to model proper responses for students and residents.
We do appear to make behavior changes after committing mistakes[8]. One study of residents reported that 98% made some change after committing a mistake. Usually this involved paying more attention to detail (82%), personally confirming clinical data (72%), seeking more clinical advice (62%), ordering more tests (26%), and making defensive changes (18%) [7]. Two primary lessons that they reported learning were tolerating others' mistakes and communicating better. While addressing how we deal with mistakes should be a part of medical school and residency training, these points are applicable to non-teaching departments as well.
Mistakes will occur. Our current medical and societal cultures often make dealing with
mistakes difficult. Yet the health of our patients, the medical system and that of ourselves demands that we discuss mistakes openly in a benign environment. Each of us can work to create a more receptive environment to discussing mistakes. Let us learn from our mistakes.
Residents and junior staff should consider doing the following
when mistakes are made:
- accept responsibility
- discuss mistakes with patients and their families
- discuss your feelings
- talk about mistakes with your attending or senior staff
- learn from others' mistakes and make practice changes
Teaching faculty and senior staff should consider the following:
- create a non-threatening and non-judgmental atmosphere - discuss mistakes at the beginning of rotations, internship, job orientation
- provide emotional support, validate reactions and reassure
- help residents and junior staff interpret their distress
- model appropriate responses - share stories; incorporate mistakes into the learning process
- provide supervision to prevent mistakes, and to detect them early when they occur
- institutionalize a forum to discuss mistakes and explore related feelings in a healing way
REFERENCES
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2. Schimmel E. The hazards of hospitalization. Ann Intern Med, 1964. 60: p. 100-110.
3. Steel K, Gertman PM, Crescenzi C, et al. Iatrogenic illness on a general medical service at a university hospital. N Engl J Med, 1981. 304: p. 638-42.
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5. Leape L. Error in medicine. JAMA, 1994. 272: p. 1851-57.
6. Light D. Uncertainty and control in professional training. J Health Soc Behav, 1979. 20: p. 310-22.
7. Wu AW, Folkman S, McPhee SJ, Lo M. Do house officers learn from their mistakes? JAMA, 1991. 265: p. 2089-94.
8. Christensen J, Levinson W, Dunn P. The heart of darkness: The impact of perceived mistakes on physicians. J Gen Intern Med, 1992. 7: p. 424-31.
9. Shuster E. Fifty years later: The significance of the Nuremberg Code. N Engl J Med, 1997. 337: p. 1436-40.
10. Witman A, Park D, Hardin S. How do patients want physicians to handle mistakes? Arch Intern Med, 1996. 156: p. 2565-69.
11. Shapiro RS, Simpson DE, Lawrence SL, et al. A survey of sued and nonsued physicians and suing patients. Arch Intern Med, 1989. 149: p. 2190-6.
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13. Ely JW, Levinson W, Elder NC, et al. Perceived causes of family physicians' errors. J Fam Pract, 1995. 40: p. 337-44.
