Time and again it has been proved that when a doctor acknowledges a mistake and engages the patient instead of ignoring or denying what happened, everyone’s interests are served. Our blog from last year, “Admitting Errors Is the Right Thing to Do,” explained why this approach creates a culture of honesty within the medical profession, is good for patients and reduces the incidence of medical malpractice lawsuits.
“My Near Miss,” an op-ed published last month in the New York Times, is a personal, poignant account of an emergency department doctor’s mistake and how it made her realize that she, and any other medical professional who errs, must step up and admit it.
Dr. Danielle Ofri, author of the book “What Doctors Feel: How Emotions Affect the Practice of Medicine,” recounts the day she neglected adequately to review a CT scan, an oversight that could have spelled death for her elderly patient had someone else not paid attention. It was the end of a long day, and the ER staff was keen to move their patients to other hospital departments.
This patient’s problem-altered mental status-didn’t seem as urgent as the department’s heart-failure and raging-infection cases. She was a nursing home resident with dementia, and, as Ofri writes, “it was hard to get worked up over a demented nonagenarian who was looking a little more demented.”
Ofri hoped to move the patient to the intermediate care unit, where patients with no active medical issues waited to be discharged. But first, they had to review lab reports, a CT scan of her head and a chest X-ray to make sure the patient didn’t need treatment. “But the docs at the intermediate ward left at 5 p.m. and it was 4:45,” Ofri writes. “I quickly scanned through the labs, called the ward’s doctor and ran through the case – demented patient, still demented, return to nursing home tomorrow.
“I remember the doctor’s voice so clearly: ‘You’re sure the labs and everything are normal?’ Yes, yes, I said, everything is fine. She hesitated, then said OK.” Ofri and the intern she was working with happily moved on to other patients.
We can all understand this mind-set-who hasn’t been eager to dispose of an annoying or uninteresting chore in order to get something more meaningful done?
But that patient, it turned out, was hardly uninteresting. A radiologist reviewing the CT scan that night had seen intracranial bleeding, and notified the intermediate care unit doctor. The next afternoon neurosurgeons were draining the blood from inside the patient’s skull.
Ofri was horrified. As she explains, “You couldn’t do much worse than miss an intracranial bleed.”
“I had failed to check the head CT! I was appalled at myself, mortified by my negligence. I stumbled through the rest of the day, an acrid mix of shame and guilt churning inside me.”
As Ofri says, no one knows how many of these “near miss” medical mistakes occur. Probably many more than the number of known errors. According to a 2006 report by the Institute of Medicine, medication errors alone affect 1.5 million patients a year.
Ofri never told anyone about her lapse-not the intern, the attending physician nor the patient’s family. She wrestled with a variety of escapes: the radiologist had caught the problem, no additional harm had come to the patient…
But if that patient had been discharged, or if Ofri had prescribed something ostensibly harmless, like aspirin, the patient could have bled to death. “The patient was simply lucky,” Ofri admits.
Ofri learned a lot that day and is a better doctor for it. She reminds readers that the attention now being paid to reducing medical errors is bearing fruit. Electronic prescriptions help to avoid penmanship mistakes. Wristband bar codes help to ensure that medications go to the right patient. Surgical checklists help to prevent common oversights.
“But we can stop only the errors we know about,” she says. “There remains a black hole of near misses, of uncharted errors-a black hole of shame that prevents caregivers from coming forward.”
That hole is the inability or unwillingness of a medical professional to acknowledge his or her mistake.
Ofri says that most medical professionals keep these “shameful mistakes” to themselves, as she did. But she never forgot how it felt, and for her book, she interviewed doctors about the emotional experiences that have molded them; nearly all remembered a medical error that they had been party to and many had never spoken about it before. “The shame of their errors-including the near misses-was potent, even decades later.”
We agree with her prescription for this malady: Leaders have to stand up and cop to what happened. “Hearing how a person in authority handled the emotional fallout and the feelings of incompetence may give others the courage to come forward,” she says. “Until we attend to the culture of shame that surrounds medical error, we will be only nipping at the edges of one of the greatest threats to our patients’ health.”