Doctors are not infallible; they are human and make mistakes. Occasionally, they know of their mistakes; sometimes, others are aware, while they remain oblivious and other times still, nobody knows that a mistake has occurred. With so many things happening without a clinician’s knowledge, it is not a question of “if”, but “when”, they will find themselves having made a mistake and when they are hit with the realisation of it having occurred, their hearts usually sink.
There is a professional duty of candour upon healthcare professionals which states that all healthcare professionals must be open and honest with patients when things go wrong. The duty extends beyond individuals and addresses organisations, also, which should support individuals to report incidents. Furthermore, the guidance makes mention of encouraging a learning culture.
To help foster such an environment, healthcare professionals should remind themselves that mistakes in medicine tend not to result from a single individual’s actions. They tend to result from a series of incidents occurring as a result of the actions, or inaction, of many.
Sometimes they occur despite clinicians’ best and concerted efforts. On paper, many appreciate this, but in practice, considering the comments, behaviour and actions that ensue in an aftermath, it seems that a blame culture is still suffocating staff, even from within healthcare settings. An unofficial manhunt sometimes takes place, leaving staff feeling demoralised, demotivated, embarrassed, and blamed.
Simple changes to the way in which clinicians themselves react to mistakes can save them from damaging the reputation of others: it is not necessary, for example, to backbite or mention names in a public setting. A need-to-know basis should be adopted, especially when facts remain unknown. Sometimes, people need to be identified, but not for the purpose of gossip, lest things descend into a playground “oh-my-gosh-did-you-hear-about-so-and-so?” scenario. It would be more appropriate to speak to those concerned in private; they are more likely to take heed this way.
When reacting to mistakes, the path of least resistance is sometimes sought and focus placed on individuals, when it is often systems and cultures that need correcting. Somebody may be picked on, spoken to and given things to learn from. People then feel better, thinking they have enacted on a mistake, yet in reality, only part of the problem has been addressed.
It seems easier to suggest improvements to a junior clinician, than to suggest the same to a senior, even though seniority does not shield them from errors. Similarly, for some, it is easier to point fingers at everybody except themselves. There is room for improvement in all of us.
Clinicians are generally good at reminding each other of knowledge and experience based learning points, but less so about professionalism-based learning points. When the language used to respond to mistakes is condescending and demeaning, it creates an apprehension to discuss mistakes. Scared and threatened individuals find it harder to be open and honest. It is a skill in and of itself to know how to handle mistakes, how to approach people and advise them. If done incorrectly, a learning opportunity becomes lost: when reflecting on an incident, individuals may not remember to do X in the future, but they will remember the way in which they were treated and made to feel.
We need to continue working towards developing a blameless culture in medicine. Trying to internalise good character and conduct may take us a step towards this goal and ensure more is learnt from mistakes. Clinicians sometimes find it hard to discuss mistakes because they expose their weaknesses and limitations, but when dealt with in the correct way, they can serve as catalysts for development.
With almost one in 10 doctors feeling bullied, working environments are sometimes tense. We should not make things harder by pointing fingers. If we as clinicians are happy to play the blame game, or sit back and watch it being played, then when the tables are turned and the finger is pointed at you, ask yourself who is responsible for this culture. The realisation that you may have contributed to it may be as heart-sinking as the realisation of having made a mistake.
No competing interests:
Artaza Gilani works at Homerton University Hospital NHS Foundation Trust, London.