While reviewing resident notes and patient charts after a busy day on the pediatric unit, I came across a mistake. It was a mistake that led to the discharge of a patient who should not have been discharged. As the attending physician, I was ultimately responsible for the error, though it was based on incorrect information that had been presented to me. As I navigated the familiar spiral of emotions—from anxiety at the possibility of a negative outcome for this patient, to disappointment with myself for not double-checking the information, to frustration at the mistake—it struck me that the culture around errors in medicine is largely one of avoidance and fear.
Every physician who supervises clinical trainees has encountered the tension between balancing the need for learner autonomy to allow for growth into independent practice, with the need for close supervision to ensure patient safety and avoidance of medical errors. Within this tension, the inevitability of mistakes looms large. The reality is, even if we want to double check every aspect of the work of those we supervise, this may not be feasible given the limitations on our time in the setting of a busy inpatient service. For many of us, the question at the forefront of our minds becomes how to avoid mistakes in this context. We may spend significantly less time contemplating how to address them in a manner that fosters growth and provides opportunity for learning.
In the high stakes realm of clinical practice, we are implicitly taught not to own up to our mistakes and to judge others harshly when they do err. The general and understandable sentiment is that mistakes are unacceptable when human life is at risk. Yet the fact remains that miscalculations, oversights and omissions happen, even to dedicated physicians doing a very thorough job. In fact, those clinicians are the ones most likely to become aware of their mistakes and may end up feeling that they err more often than their peers.
This culture of silence often leads to feelings of shame and dread when we realize we have made a mistake, along with judging ourselves too harshly. In turn, these feelings bring about defensiveness rather than openness to learning from our mistakes. Transparency about our own errors may allow us to break through this cycle of negative emotions and begin an honest exchange that lets us examine systematic contributors such as communication breakdown, insufficient supervision, gaps in a trainee’s (or our own) clinical knowledge, fatigue, understaffing and other concerns. Crucially, it also allows us to address the mistakes of those we supervise in an empathetic and constructive way rather than a punitive one.
We may fear that admitting to errors will make us appear incompetent in front of the residents and fellows we supervise, the colleagues we interact with, or the patients we treat. We may worry that others will not respect our judgement after learning that we were wrong. We may even question our own competence and ability. Yet in our role as teacher and supervisor we have an obligation to lead by example and by doing so help learners navigate their own relationship with medical errors. As was the case with my patient, the “best” mistakes are the ones that a) we realize we made and b) don’t lead to any negative outcomes despite having had the potential to do so. Unfortunately, these are generally the cases that do not make it into a morbidity and mortality conference or even an informal discussion. This is regrettable because catching errors and addressing them is, in fact, excellent prevention for future bad outcomes. For better or worse, our medical mistakes shape our clinical practice both consciously and unconsciously. By failing to discuss them openly we may miss the opportunity for a proactive rather than a reactive approach to their impact going forward.
Striving for excellence in patient care does not compel us to eliminate any suggestion of error, but rather forces us to confront the painful reality that errors will be made. This is the cost of practising medicine. By cultivating a culture of transparency around medical mistakes we may mitigate this cost to ourselves, our patients and the generation of physicians we are training.
Alice Hucko is a neonatal hospitalist at Cedars-Sinai medical centre Los Angeles
Competing interests: None declared