Have you ever made a mistake? Have you ever made a mistake that harmed a patient? Do you still think about that mistake, even if it’s years ago? Me too. We all do it – mistakes range from the generally minor, like calculating a NEWS wrong, requesting an X-ray on the wrong limb (or the wrong patient) from triage, forgetting to do a repeat ECG, all the way to the catastrophic – giving the wrong patient a drug so they have an anaphylactic reaction, transfusing the wrong patient, getting a paediatric dose wrong by a factor of 10. This blog isn’t primarily about why we make errors (you can read more on that here), but about the effect they can have on you and your team.
I made my error at around 1.30am on 1st Feb 2010. I discharged a patient from the ED to the police cells, where he had a cardiac arrest at 4am. He died on intensive care 24 hours later. I heard about it by phone sometime that afternoon. The five worst words to say to any emergency physician.
There were lots of reasons why I hadn’t registered how sick he was before I discharged him. The workload was heavy that night – it was a winter weekend in a busy inner-city ED and the early evening had been bad enough that the on-call consultant had come back in from home. I was trying to clear the minors stream before finishing at 2am to give the night team a fighting chance, I was the senior doctor, trying to keep an ear open for any problems the juniors might be having. I’d seen the patient earlier so I circumvented the systems for him – when a police officer popped his head in to say he was in the back of their van, I said to bring him straight through rather than have to go through the triage process. The previous notes had been mislaid, so I relied on my memory.
Notwithstanding this, a relatively young man was dead in police custody and mine was the last signature in his medical record. There was a police investigation. It involved potential criminal charges and took eighteen months, but eventually it was dropped. I’d been away from work for those 18 months but I could go back, to a different hospital. I began to find my feet, but after a couple of months the GMC got involved in the original case, and I made another mistake.
I missed a STEMI. Admittedly the patient had no chest pain, and her COPD was an entirely plausible reason for her shortness of breath, but the STEMI was floridly there on her ECG that I looked at and signed. So why another mistake? Surely I should have learnt from the first one? We know that beyond a certain level, anxiety and catecholamines impede rather than enhance performance. Whether it’s an exam, an interview or meeting the in-laws, stress makes us sweaty, shaky and incoherent. But within the workplace it impedes selective attention, making us more distractable. So I was less able to to tune out the ringing phone, the other conversation at the desk, the arriving paramedics, to look at the ECG.
A threat response with an associated cortisol rise impedes working memory and memory retrieval, and triggers a rise in heuristic decision-making – our use of immediate pattern recognition and mental short-cuts. This makes sense – it won’t work evolutionarily if I stop to consider carefully whether that odd shadow in the bushes in front of me is a tiger. It did mean though that I jumped cognitively straight from “nicotine-stained, SOB”, to “COPD” without thought of any alternative explanations. Medical students placed in a stressful simulated consultation were less able to identify clinical features that supported an alternative diagnosis than their more relaxed colleagues. So as I was handed my patient’s ECG, I underwent premature closure – I’d already seen her, made a provisional diagnosis, started treatment. I simply wasn’t receptive to new information which might have made me reconsider my diagnosis.
And what of my team? The patient was in a resus bay with experienced nurses – why did one of them not pick me up, challenge me about the ECG? We know that nurses interviewed after clinical incidents report persistent feelings of loss of trust – I was relatively new to them, I’d arrived with a cloud of error over my head, I was chronically stressed and spiky – why would they? Also, a stressed team becomes more hierarchical, and team leaders become less receptive to information from team members, while team members under stress shift from a team to an individual perspective.
Healthcare is a perfect storm for error that traumatises the error-maker as well as the injured party; we work in a complex, high-stakes system, where mistakes are as inevitable as they are critical. Society places a burden of expectation on us – nurses, doctors, health professionals should be somehow beyond error and emotion. If we aren’t we should be punishable and liable.
So there I was, the doctor who got it wrong. What I felt was not guilt for any errors, but shame.
Rather than knowing I had done something wrong, I WAS the wrong thing. Medicine is, to a greater or lesser extent, a performance art. Even as we choose to make shared decisions with our patients, we need to inspire confidence in our competence and trustworthiness. And so we develop a “mask of infallibility”.
When an error occurs, that mask is exposed – our superiors, regulators and team-mates examine it. We erode it from within with self-questioning and self-doubt. Shame is a powerful emotion – your actual self has fallen short of your ideal self, and this is hard to take. In 2 years in the UK, 13 doctors died by suicide while under GMC investigation.
And remember this? A prank call about a royal pregnancy. And a nurse so destroyed by a single mistake which harmed no-one that she hanged herself. Medical students feeling shame in an allegedly educational environment reported feelings of being “the worst”, “the dumbest person here”.
So how do we and our teams move on from error? Much like bereavement, there seem to be a number of stages through which we progress. The first realisation of error can come at a chaotic point – the patient may still be in front of you, you may be trying to run the clinical response to the error at the same time as assimilating the fact of the error itself.
Next, the intrusive reflections, the rumination. These can be internalised, or inflicted on colleagues or family. What if I’d insisted on seeing him walk myself? What if I’d checked another blood pressure? What if I’d X-rayed his pelvis?
Then follows a prolonged phase of restoring personal integrity, which often runs alongside surviving the inquisition. At the same time as managing your own “what if?”s, you wonder what is being said about you in the coffee room. Who can you talk to? Will you employer sacrifice you for their institutional reputation? Will you lose your licence and your income?
Will you go to prison? Who can you trust? I was investigated by the police, my regulator, my employer, my training scheme. People I thought were there to support me sent emails saying my personality couldn’t be trained out of me. I was summoned to senior management offices and told I could be sacked. My experiences are not unique.
Individuals cope with this in a number of ways. Social support is the most frequently cited; talking, asking for advice. But this is removed from many – legal restrictions, confidentiality concerns, exclusion from the workplace, professionals who are already far from home and family for work. Social media may fill some of that gap, but how safe can it be? Where could those screenshots end up? Accepting responsibility may be emotionally helpful – change the system, or apologise to the victim. Yet many times we are prevented from doing this by legal liability concerns – if I apologise, will the lawyers say that proves it’s all my fault?
Most of us will recognise the less productive coping strategies – distancing, pretending nothing has happened, everything is OK, in my British case keeping a stiff upper lip and insisting it will all be fine with a cup of tea, burying our emotions in work, food or alcohol.
If we continue to work through this phase, our reactions can put more stress on our team. Fear, doubt and emotional pain can be perceived as anger, hostility and apathy. Without a team that is on our side, we risk becoming more isolated, more stressed, more error-prone.
Eventually, most practitioners involved in an error find one of 3 paths. They may leave; some will change specialties or hospitals, they may decide healthcare is no longer for them or move into non-clinical roles; their mask is so damaged it cannot be rebuilt.
Others will survive; they return to practice but are never quite the same. They do not achieve self-forgiveness, their mask is present but fragile. They may exhibit defensive practises like over-investigation, over-admission, delaying disposition till handover so another practitioner has to make decisions.
A final group survive and thrive. They remember and learn from the event at the same time as allowing themselves compassion. They rebuild their shattered mask with their experience.
My colleagues and friends are the golden lacquer on my kintsugi bowl – they took me from the broken practitioner I was in August 2012, steered the pieces of me back to clinical functioning and psychological heath, and welcomed me as a member of the team who brought value. I am not the same emergency physician I was in 2010, I am scarred by it, but I am more willing to accept fallibility, to reconsider, to think out loud, to know that I don’t know.
Competency framework GNP 1.2, 1.3, 2.1, 2.2, 3.1 Kintsugi bowl image kindly provided by Ross Fisher @ffolliet