Medical error is a name we put to human mistakes in medicine. Mistakes that can lead to a range of consequences from serious injury to death. If you’re lucky, the mistake has no negative effect, but at its worse it can cost someone’s life. In medical school we don’t get taught about the very real future of us making mistakes. We all have heard of the horror stories, but think “that would never happen to me”. But, what about when it does?
In other professions they try to relax their workers by saying, “what’s the worse that can happen? It isn’t like people’s lives are at stake”. Unfortunately, the worse that can happen in medicine is in fact very very bad. There are actual real lives at stake, so this phrase isn’t very relaxing at all.
As a medical student we think our main concern is to pass exams and get better at inserting IV cannulas. We do know that we need to ‘break bad news’, and even get taught an acronym called SPIKE that helps achieve this.
Besides this poor acronym we don’t get taught much else about ‘bad news’. We also assume the news is an unavoidable fact, something that happens because of bad luck. A cancer diagnosis for example, can’t really be blamed on anyone. It is terrible, but it just happens.
What we don’t get taught is how to ‘break bad news’ that you have caused. Or played a part in. How to deal with those mistakes that were avoidable. And how to deal with yourself after making an error that may have cost someone’s life.
It happens to everyone
What they don’t tell you is that mistakes happen. Every single doctor has made a medical error that lead to ‘poor patient outcomes’, or has been part of a decision making process that ended up badly for a patient. There is a huge spectrum of mistakes from incorrectly prescribed medications, missed diagnoses, to wrong legs being amputated.
Even one type of procedure the central line, has a huge list of possible mistakes – you hear about doctors losing wires inside patients, puncturing lungs, air embolism to brains, tearing vessels…
Even the best doctor is not immune to missteps. So why do medics not speak of it when it is actually inevitable?
I think being more aware of this fact and how to process it is essential for any ‘good doctor’.
My first error
When I had my first major medical error I was inconsolable for a long time. It was an elderly man who had not opened his bowels in more than a few days. I was working the evening shift, covering over 100 patients myself.
I had prescribed laxatives, assuming the patient was constipated. It was just one of 10 patients that evening who needed help going to the toilet. Another job on my ‘tasklist’* that I had to do, that continued to grow no matter how many things I ticked off. That mixed with multiple emergency calls for deteriorating patients, I wasn’t too concerned on hearing he hadn’t opened his bowels. I was not told any other information, and he was stable. I prescribed the laxatives and thought nothing of it, I didn’t take the time to see the patient (I was already behind enough on my jobs I thought). Mistakingly, I assumed the description on the task list was enough, and saw the day team had seen him this morning with no other concerns.
*The task list is an electronic list of jobs you need to do. It’s meant to be non-urgent things.
Months later I was called by the body that investigate medical errors. This patient had ended up deteriorating later that evening. He had a large bowel obstruction. Months after that evening he died, not able to recover.
Swiss Cheese Model
Writing about it is very difficult. I agonised over this error for months, I still think about it. What if I had discovered the diagnosis? Would he still be alive? Or would it have still ended up the same way? I was a few months into my first year working as a doctor. One of my colleagues told me that they had seen that case happen a few times, saying it was quite common. The medical indemnity lawyer reassured me that it was nothing to be worried about. In medicine the errors that occur are often not one thing going wrong, but a series of errors that line up to cause a disaster. What they call – the swiss cheese model, where all the holes line up.
Apparently, it wasn’t all on my shoulders. There were other doctors involved in their care, besides me that one evening. No one had called or paged me to say their concern. It was added to the task list that was meant to only have non-urgent things. Also a lot happened between my one interaction with this man, and the two months until his death.
In the end the lawyer was right. It still didn’t help with my guilt.
Photo from Sketchplantations
Trust no one
Unfortunately, one of the main things I learnt from this was to trust no one (in medicine anyway). It may seem dark and cynical, but I have found it stands me in good stead every time. I need to see everything with my own eyes.
As the rules of Intensive Care state: assume nothing, trust no one, give oxygen (enough, not too much).
If I had of seen the patient for myself, there may have been an entirely different outcome.
The support and advice I was given
My seniors reassured me. Saying that nothing I did contributed to the events that unfolded. That laxatives would not have worsened the situation, and that these types of errors are not blamed on an individual, but the system as a whole.
A senior surgeon told me, “this is your first mistake but it won’t be your last. I’d like to say it gets easier but it doesn’t.”
I was astonished. Everyone acted so nonchalant from my peers, to my seniors, counsellors and the lawyer. Without batting an eyelid, they said these things happen and will continue to happen. I heard their advice, but couldn’t believe it.
I was at the point of breaking, and could not sleep, eat, or enjoy life.
My work was becoming more and more demanding, and I was not coping. I asked for time off, a week even.
No luck, everyone expressed their sympathy, but doctors are expected to just work through it.
Things go wrong even if you do everything right
After this event I became very scared of making a mistake again. I thought by sheer willpower I could avoid any future errors. Unfortunately, this is impossible. Medicine is not a perfect science. Things go wrong no matter your best efforts.
Months later I faced my next similar bad situation. A nurse put on the task list that a patient (Mr Smith let’s call him) was vomiting, “please chart antiemetics”.
A red flag went off in my head. Uh-oh. Patient is vomiting, I call the nurse and ask when the patient last opened his bowels. She wasn’t sure. I decided to go check it out myself, knowing all too well the devastation that bowel obstructions can cause.
I arrive to see Mr Smith and from the hallway I can tell he probably had a bowel obstruction. This poor man was stooped over, abdomen distended, holding a vomit bag. He was in his 70s, and had a long list of other illnesses including severe pulmonary hypertension that was being managed palliatively.
“He just told me he last opened his bowels about 6 days ago, so I gave him a few laxatives,” the nurse looking after him said.
Dammit. I go up to assess him, and I can’t hear bowel sounds. His abdomen is huge and sore. He feels terrible.
“Keep him nil by mouth, I’ll order an urgent abdominal xray,” I tell the nurse. I then relay this to my senior who agrees with the plan.
The x-ray came back and it confirmed my suspicion. I called the surgeon.
He arrived immediately to the patient’s bedside. We explained our findings to Mr Smith and he declined a surgery. He said he would rather not recover from the obstruction. Mr Smith was already not for CPR, ICU or ventilation. He did however agree to a nasogastric tube (NGT). The surgeon managed to get the NGT down Mr Smith, but within a minute of having the tube down Mr Smith died suddenly.
I was devastated. I had found the diagnosis, and I had called the right people. It still wasn’t enough, and Mr Smith had died. The only consolation I had was that he had said he didn’t want to recover, he seemed largely at peace with leaving the world.
Is this a taboo subject?
As Dr Gawande writes in his book Complications:
The fact is that virtually everyone who cares for hospital patients will make serious mistakes, even commit acts of negligence, every year. For this reason, doctors are seldom outraged when the press reports yet another medical horror story. They usually have a different reaction: That could be me. The important question isn’t how to keep bad physicians from harming patients, it’s how to keep good physicians from harming patients.dr atul gawande – complications
How do we keep good physicians from harming patients and why don’t we speak about it more openly?
Some things that could help would be better staffing, less overtime, and more senior support. Working your 100th hour with little sleep will affect your performance. Being a few months into your first job as a doctor without senior assistance is dangerous. We can do better.
Don’t die over your mistake
Easier said than done.
When you make a mistake so horrible it’s to die over, don’t….I have blundered horribly and no one can make me pay more than the price I exact from myself…As a doctor, I must keep myself intact while I wall off the horror of human imperfection. Until the next time.oscar london – kill as few patients as possible
As the man behind the pseudonym Oscar London says, no one can make me pay more than the price I exact from myself. Long after the investigation is closed, and after the civilised talk on how to avoid this type of mistake in the future, I continue to punish myself for my errors.
How can anyone live and be okay with such a deadly mistake?
Ex-doctor Adam Kay quotes a consultant who tells her trainees that, “by the time they retire there’ll be a bus full of dead kids and kids with cerebral palsy, and that bus is going to have their name on the side”.
Sometimes medicine is about trying the best you humanly can, and living with the good and the bad. The highs and the rock bottom lows. Learning from your mistakes and living with them.
As I was told by the senior surgeon – I wish I could say it gets easier, but it doesn’t.
Sometimes I wonder, can I continue working in a profession with such high stakes?
My tips on getting through the grieving period
- Don’t dwell on the ‘what ifs’, it won’t help the patient or you. Focus on the now and what you can do in the present moment
- Speak to someone about it – friends, family, seniors, co-workers
- Get professional help – if you don’t already, find a great counsellor and GP
- Be kind to yourself – light a candle, go for a walk, eat a nice meal
- Forgive – yourself and others
- Learn from the mistake, and what you will do differently in the future
- Write about it – sometimes this is easier than saying it aloud
- Give it time
- Your emotional reaction is valid, let yourself feel it and don’t let anyone minimise how you’re feeling
- Speak to your lawyer – the medical indemnity lawyers exist for a reason. Call them and have a chat. Sometimes knowing the facts can make you feel at ease, instead of imaging worse case scenarios
I hope this article has helped you in some way, I tried to be as open and honest as possible. I feel like we are missing discussions like this in the health profession.