It’s a good job Frank Sinatra wasn’t a clinician…
Crooning “Regrets, I’ve had a few, but then again… I can never mention them because there’s an inherent denial of error in healthcare,” doesn’t exactly have the same ring to it, does it?
Ol’ Blue Eyes aside, I’ve been thinking a lot about mistakes recently. I’ve been thinking about the mistakes that we make as doctors and nurses and how they have irreversible effects on the lives of our patients. And I’ve been thinking about my own mistakes. How I have missed diagnoses, delayed treatments, discussed plans insufficiently and how this has impacted the lives of the patients who trusted me with their care.
And as well as reflecting on these errors and how they forever change the lives of our patients, I’ve been thinking about how they affect us as clinicians and how best to learn from them. And, paradoxically, how we never speak about them.
Humans make mistakes. Outside hospital we admit these mistakes, own up to them with people we trust and try not to repeat them again. Yet what is taken as normal in everyday life doesn’t work in healthcare.
Why don’t we discuss our mistakes?
Firstly, litigation. There’s an understandable sensitivity around talking about what’s gone wrong as it leaves us open to malpractice cases. Cases like that of Hazida Bawa-Garba – a doctor struck off for missing sepsis – does little to dispel this. There is a feeling that the legal vultures are just waiting to close in after every slip-up.
Then there is shame. There is a deep personal shame in making mistakes. We are taught that only juniors make mistakes and we grow out of them as they become more senior. There is therefore an inherent unwillingness to admit we make mistakes as we become more senior; we should be above this.
And in addition to the personal threat of shame is the societal threat of ridicule. Healthcare is a competitive field where we only show the best side of ourselves to our peers. In opening ourselves up to become ‘the guy who made that mistake’ there is a vulnerability we’re not prepared to accept.
The organisation threat of litigation, the personal threat of shame and the societal threat of ridicule by our peers is a powerful combination. And a combination that coalesces to form a more general fear – if we do admit our mistakes we will be alone.
The fear of ridicule distances us from our peers. We fear the institution we work in will distance itself from us in litigation. And the removal of these two vital supports – colleagues and organisation – leaves us alone and adrift when we are least prepared to deal with it.
Does discussing mistakes matter?
In short, yes. If we don’t discuss our mistakes, it is impossible to learn effectively from them. There is a wealth of evidence that debriefing on mistakes improves future performance. This effect comes not only from learning from our own mistakes, but learning from our colleagues’ errors. In not discussing our mistakes as a group we are depriving our colleagues of the knowledge they could have gleaned from our mistake and the rich vein of potential for broader error reduction has been lost.
This error reduction is not just in relation to other clinicians avoiding specific mistakes. Most errors are not due to a ‘bad clinician’, rather the same or similar medical errors have been made many times before in many different ways by many different clinicians. And errors are rarely due to one clinician happening to make a mistake. They are a combination of a huge number of factors that align to make an error. Therefore in not discussing as a group we are not only depriving our colleagues of knowledge, but we are leaving the system open to ongoing failures by not identifying system-wide faults.
Brian Goldman discusses the culture of mistake denial in medicine in his 2010 TEDX Talk: Doctors Make Mistakes. Can we talk about that? Goldman talks about his own experiences of making mistakes and argues we need to find a way to embrace that in a more constructive way.
Goldman closed his TED Talk with a call to action for the medical community to redefine its attitude to mistakes, to find ways to openly and sympathetically discuss them in order to better learn from them. That was almost ten years ago and I’m not sure we’ve answered his rallying cry yet.
So what can we do?
There is still hope, and it starts in medical and nursing school.
We must teach medical and nursing students that mistakes are inevitable in a high pressure field with exponentially increasing complexity and pressure. Only in doing this from the start, in teaching students to be comfortable with uncertainty and that mistakes are inevitable in an uncertain world, will we begin to change the tide.
Companies such as Oxford Medical Simulation are actively trying to create a safe space in which to consider clinical mistakes that Goldman so rightly encouraged us to cultivate.
OMS builds lifelike but non-judgemental virtual reality scenarios in which students can see and treat patients like in real life. This allows learners to make mistakes in the virtual world rather than in real life, without any sense of reprisal.
Reflection and debrief on performance is built into the system, guiding learners to discuss errors, before providing structured feedback on performance. In this way, learners are in control of building a culture of supportive discussion of error.
While it is key to embed a culture of discussing errors at medical or nursing school, this is not enough. Once clinicians have been taught that making mistakes is normal, that discussing them is vital, and that this can improve patient care, we need to have systems that support reporting of these errors, to disseminate knowledge.
Reporting of mistakes, reporting of near-misses, reporting of anything that might compromise patient care should be the norm. And this should be true from the porters through the clinicians to the CEO.
To do that, we have to extricate the shame loaded into such discussions of error. Though a broad culture change to make error reporting the norm will take time, one simple way to help this is anonymisation. Building simple, anonymised reporting systems into hospital infrastructure – where an error is reported to the patient safety team, a collaborative action plan is formed and reported back to the clinical team without fear of reprisal – is vital. None of this is difficult, and it will surprise many people outside healthcare that this is not the norm in more hospitals, but all will help create a system that helps identify and supports rather than punishes.
Finally, the systems above are worth nothing if not supported by patients. It is imperative that patients and the public support and can contribute to the structure of such systems – what clinicians and hospital managers feel is important can be very different from the patient voice.
Alongside this, patients and the public must begin to accept that in a complex system, doctors will make mistakes. Healthcare is an imperfect science – many of the decisions we make are based on little or no evidence. In a world where new treatments are being invented daily and conflicting evidence is produced at the rate of 1,000 papers per day, clinicians cannot know what the ‘correct’ course of action is in many cases.
Often the ‘correct’ course does not even exist so we make 50:50 calls.
Combine this with a workforce that is understaffed, overworked and burned out and there is no surprise that mistakes are made so frequently. That is not to accept mistakes – it is to accept what we cannot change, identify what we can change, and target this actively.
Like the patients we harm, we carry our mistakes with us for the rest of our lives.
Arming our clinicians with the resources to acknowledge, reflect on and learn from their mistakes is crucial to identifying areas for growth and improving patient care.
Dr Jack Pottle is a practicing doctor, member of the Royal College of Physicians and Medical Director of Oxford Medical Simulation