To err is human, says the Institute of Medicine. But, as humans, we sometimes find it difficult to admit mistakes.
Nonetheless, it is important to be honest about errors for a number of reasons. “Admitting mistakes is the first and [an] essential step in learning from them,” said Margaret Plews-Ogan, MD, MS, Bernard B. and Anne L. Brodie Teaching Associate Professor of Medicine and director of the Center for Appreciative Practice at the University of Virginia in Charlottesville. “Talking about them openly expands that learning to your colleagues.”
James Stankiewicz, MD, professor in the department of otolaryngology head and neck surgery at Loyola University Stritch School of Medicine in Chicago, is well published on the topic of the importance of admitting errors. “If you can’t admit that there are problems with a technique, instrumentation, or packaging, you’re keeping important information from colleagues that might keep them out of trouble,” he said.
Along those lines, Dr. Plews-Ogan added that acknowledging our human fallibility also helps us to design systems that can protect us from our own, often predictable, imperfections. The bottom line, even though it may sound contradictory, is to view an error in a beneficial way. “Turn it into a positive,” Dr. Stankiewicz said.
Where We’ve Been
Not too long ago, the medical community was mostly closed mouth when something went wrong. “I don’t think people actively covered things up, but they were very loath to talk about them,” said Mark Wax, MD, professor of otolaryngology-head and neck surgery at Oregon Health and Science University School of Medicine in Portland. “Nowadays, it’s become more commonplace to have open discussions about errors. In our department, we discuss all errors and complications. If you admit a mistake and then try to rectify it, it is much better for patient care.”
Looking back, Dr. Plews-Ogan also recalls working in an environment where nobody talked about making mistakes. “We wrongly assumed that perfection was the norm,” she said. “But this is a dangerous and obviously flawed assumption. Instead, we can role model our own awareness of fallibility, be open about acknowledging our mistakes with patients, and be eager to discuss our mistakes with a keen desire to learn and create a safer system going forward.”
Dreading the Consequences
Despite the benefits of being honest about errors, many physicians have well-grounded fears about letting others know they failed. For one, they may fear how they will be perceived by others. “If you admit error to colleagues and partners, they may think less highly of you or be critical,” Dr. Wax said. “Even worse, there might be backlash at the department or hospital level, or referring physicians may stop sending you patients, and you won’t have a practice left.”
Physicians may also be naturally concerned about what a patient will do if you admit error. Will they stop seeing you? Will they sue you? “But the majority of the time, patients will understand, and you will be able to reach a consensus on how to make a resolution regarding the consequences,” Dr. Wax said.
In fact, Jennifer Lavin, MD, assistant professor in the division of pediatric otolaryngology at the Ann and Robert H. Lurie Children’s Hospital and Northwestern University Feinberg School of Medicine in Chicago, reports that several studies have shown that disclosing adverse events to patients and families has not put physicians at increased risk of litigation. Currently, the nonprofit organizations Sorry Works and Medically Induced Trauma Support Services are working to disseminate this message to providers.
Onward and Upward
How can physicians move forward after making an error?
A recently published paper by Dr. Plews-Ogan and her colleagues, “Wisdom in Medicine: What Helps Physicians after a Medical Error?” offers ways physicians can move through the experience of making a harmful error (Acad Med. [Published online ahead of print September 4, 2015.])
One suggestion, in light of the fact that institutions are struggling to move from an entrenched system of shame and blame to a balanced system of personal and systems accountability, is to start a peer support program at your institution that puts each physician in touch with a trusted colleague who can help her through the process in a safe and healthy learning environment.
Dr. Plews-Ogan advises initiating a regular process of reviewing both adverse events and near misses. “That can accelerate learning and prevention strategies and at the same time create a more open environment for dealing with mistakes,” she said, adding that helping physicians cope positively after a medical error can create a more open and learning-focused environment, and can help doctors to be their best selves.
The bottom line, said Jo Shapiro, MD, chief of the division of otolaryngology and director of the Center for Professionalism and Peer Support at Brigham and Women’s Hospital in Boston, and a co-author of article, is that safe organizations have cultures where people are empowered and not afraid to raise concerns, admit mistakes, and ask questions. “While it’s easy to tell employees to do this, it’s another thing to develop and provide a culture where this is realistic for staff to do,” she said.
Under Dr. Shapiro’s leadership, her institution started the Center for Professionalism and Peer Support with the idea of supporting a culture of trust and respect throughout the hospital. As a graduate medical educator, she had been struck by some things that weren’t taught during medical training programs even though they significantly impacted patient care—such as how to deal with adverse events.
The outreach program at Dr. Shapiro’s institution involves a clinician colleague trained to provide peer support. “Because there are so many cultural, emotional, legal, and structural barriers to seeking help, we have found that even if support is available, most clinicians won’t seek it,” she said. “Therefore, a trained peer reaches out to clinicians after an error has occurred and asks if they want support.”
The colleague providing support will validate the fact that it is normal to struggle after something bad happens, such as inadvertently causing harm. “It is human and OK to have such feelings,” Dr.
Shapiro said. Then, the peer supporter will help the clinician to identify which coping tools might help him to move forward. The peer supporter may help the clinician explore what has helped him to cope with difficult life events in the past and encourage him to employ those methods in this instance.
The peer support process can also involve encouraging the clinician to be involved in system changes, so he can not only help himself but also help colleagues learn from systems issues, making the system safer moving forward. “Making things better helps the doctor, helps other clinicians, and, most importantly, helps future patients to avoid the same scenario,” Dr. Plews-Ogan said.
Studying Error Occurrences
Admitting errors, learning how to prevent them, and moving on from them continue to be growing topics in the literature. Dr. Wax and colleagues were prompted to study and publish a paper on the accidental dropping or misplacement of free flaps after a free flap was misplaced in the operating room (Laryngoscope. 2015;125:1807-1810). This had happened sporadically a few times before. “It was supposed to be on the back table, waiting to be implanted into the patient, and when we asked the tech for it, she found it in the recycling bin,” he said. “When unfortunate things happen in the operating room, we need to look at the cause and see if there is something we can do about it.”
Dr. Wax reached out to his colleagues with high-volume practices for answers. “I asked them if they had this happen, how many times, what caused it, and what they did about it,” he said. “I wanted to see if there was an underlying factor so we could implement process improvement. I also wanted to glean if there was a detrimental effect on the patient.”
Dr. Wax found that surgeons’ reasons for dropping or misplacing free flaps were very similar across the spectrum. “Every time a mistake occurred, a change was instituted to make sure that a particular circumstance didn’t arise again—and usually it didn’t happen for a while,” he said. “But over time, personnel changed, and sometimes processes we instituted changed over the course of years and the event happened again,” he added. “When asking staff about it, they admitted to being complacent about following guidelines.” In such instances, Dr. Wax would advise addressing issues and establishing a better protocol. Interestingly, Dr. Wax was pleased to learn that misplacing free flaps is a rare event, and when it does happen, it is not detrimental to the patient, because misplaced free flaps can still be used once they are cleaned.
In another instance, Stella Lee, MD, assistant professor of otolaryngology at the University of Pittsburgh Medical Center, and her colleagues were prompted to study the impact of quality improvement measures on the delivery of allergy immunotherapy (Int Forum Allergy Rhinol. 2015;5:513-516). “There was a need to evaluate preventable system-wide errors in order to make changes in the way allergy delivery was provided,” she recalls. “We realized the importance of not only reporting errors, but also the need to be proactive in tracking and analyzing the errors so that meaningful change could be made.”
After studying and analyzing errors related to subcutaneous immunotherapy, Dr. Lee’s institution developed a systems-wide initiative to make changes to prevent future errors and also improve the quality of patient care. “It was not an easy process, and instituting change was initially met with resistance,” she said. “But the efforts were measurable and positive. Having a quality metric in place allows for a quantitative approach to problems and the acknowledgement that improvements can be made. Quality measures are already being utilized to determine hospital and physician reimbursement. It is important that we participate in defining these metrics rather than letting them be defined for us.”
Admitting error in medicine is not easy, but the importance of admitting error can’t be understated. Do yourself, your colleagues, and your patients a favor—admit error, learn from it, and move forward.
Karen Appold is a freelance medical writer based in New Jersey.