January 19, 2018

To Err Is Human

Mistakes in practice are inevitable. It is what we do after making an error that can help foster—or dissuade—the culture of infallibility that permeates our profession.
By Linda Fineman, DVM, DACVIM (Oncology)
As I slowly injected 5 mL of an antibiotic I’d never heard of into a favorite patient, I couldn’t shake a nagging feeling of unease.

I finished the treatment and continued with the rest of my duties in the primary care practice where I worked each evening. The next day, Dr. Jones called me into his office and told me that the patient I’d treated the night before had received a 10-fold overdose of a nephrotoxic drug. I had misread a poorly placed decimal point. I barely held it together through the remainder of my shift, then went home and spent the next 48 hours in the fetal position, in tears.

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That mistake happened in 1986, but I still remember exactly what the treatment sheet and patient looked like. We are all human, we all make mistakes, yet I shouldn’t have.

We’ve all felt the overwhelming sense of shame and guilt that accompanies a medical error. When mistakes happen, we say to ourselves, “I’ll work harder. I’ll be more diligent. If I try harder, it won’t happen again.” The truth is, the way to reduce medical errors is to give ourselves permission to be human—to err.

Virtually everyone working in veterinary practice will make a mistake that has the potential to affect a patient’s health negatively, so it makes sense to focus on ways to reduce the risk to patients and simultaneously minimize “collateral damage” to the people involved. Medical errors don’t just affect the patient and client—they have an impact on us, our families, and our staff, as well. In turn, the stress and shame we experience after an error lead to an even higher risk of error.

Breaking the Cycle
The first step in reducing mistakes and breaking the cycle is to start talking about the errors we make. Opening up about our mistakes allows us to focus on how we can reduce the risk of future errors through improved teamwork, communication, and systems. Shifting the practice culture away from “blame and shame” and instead focusing on what we can learn from every error enables us to build systems and processes that help prevent mistakes—or at least catch them earlier. Creating a culture of openness helps make it feel safe to talk about what went wrong and why. Burnout, compassion fatigue, and mental illness are enormous challenges to our profession, and working in a culture that demands infallibility is a predisposing factor that we can and should address. By disclosing errors to our clients, we live our professional values and ethics, model appropriate behavior and standards to our coworkers, and reduce our personal suffering after a mistake occurs.

We can learn a lot from human medicine, in which studies show that medical errors are currently the third leading cause of death in the United States.1 Poor communication within teams is a major factor, and burned-out caregivers are more likely to make mistakes. Despite numerous studies showing that patients and their families want to hear about what happened and why, only about a third of medical errors are disclosed.2,3 Professional standards clearly indicate that physicians must reveal errors, yet fear of lawsuits and stigma remains a barrier. Ironically, the risk of board complaints and lawsuits decreases when doctors are open, compassionate, and direct in talking about mistakes.4

The limited research in veterinary medicine shows that we have a long way to go. In one study of veterinarians in practice less than 5 years, 78% admitted to making a mistake that affected a patient, yet only 40% disclosed the error.5

One reason for the silence may be fear of creating emotional trauma for a client. By having simple tools to facilitate conversations, however, veterinarians can reduce the lasting impact of mistakes on clients and team members. Failure to respond openly, honestly, fairly, and with empathy can lead to greater client disappointment than the error itself caused. Clients want to know what happened and why, what it means for their pet, who was responsible, and how a similar mistake will be avoided in the future. They also want to hear a sincere apology and know how they will be compensated.

A few things must occur before that conversation, however. First, address the patient’s immediate needs, and then take care of yourself and your team members. An initial assessment of what may have happened and why will help you prepare for the client discussion. Remember that adverse outcomes can happen in the absence of an error. Being clear in your own mind about what occurred is important for framing conversations with clients and staff. Finally, before approaching the client or picking up the phone, take time to manage your emotions. Shame can lead to minimizing an error or telling a lie of omission. Guilt can result in self-blame that may be inappropriate. Talking with your team and your insurance provider can help you gather your thoughts and bring your emotional reactions into perspective.

The Client Conversation
The TEAM model may be a helpful way to organize the conversation with clients: T = truth, E = empathy, A = apology, M = managing through to resolution.

Truth
It may be helpful to prepare your client for bad news with a simple statement such as “I’m sad to say that I need to have a difficult conversation with you.” Share the basics of the situation in 2 or 3 sentences, then pause and ask for permission to continue. Acknowledge that the client must be feeling a barrage different emotions, and ask what he or she would like to hear from you next. In your explanation, include what you know about what happened, what’s being done for the pet, and the steps being taken to better understand why the error occurred.

Empathy
Empathizing with the client can help rebuild trust and restore a fractured relationship. Use reflective listening to ensure that the client feels heard, his or her emotions are validated, and any concerns are acknowledged. Be sure the client’s thoughts, feelings, and needs are all addressed.

Apology
A genuine, heartfelt apology is critical when an error has resulted in patient harm. It can have a powerful impact in reducing anger and suspicion. Be mindful of the difference between an apology of sympathy (“I’m sorry this happened to you and your pet”) and a true apology, in which you take responsibility and acknowledge that a mistake was made.

Managing Through to Resolution
In human medicine, there is clear evidence that patients and families want to know that something good will come out of their suffering and that others won’t go through the same thing.6 Part of managing through to resolution requires learning from the mistake and taking steps to prevent future similar errors. This is where a discussion with the medical team comes in. Making small changes in systems and empowering everyone to have a voice in reporting what they see and think helps prevent many errors. In human medicine, for example, the use of surgical checklists has reduced patient morbidity and mortality by 30% to 50%.7,8

Making reparations is also important, and that is not just about waiving appropriate fees. Ask the client what more you and your staff can do to help. Give the client a voice, and listen closely for how you can meet his or her needs.

If handled appropriately, medical errors need not result in board complaints, lawsuits, or negative online posts. By being open, direct, honest, and empathetic, we can lower the risk of lasting negative repercussions and defuse anger. Within our profession, we have an ethical and moral imperative to change our culture to one in which we are open when we make mistakes. Instead of asking “Who did that? ” ask “What factors led to that mistake?” By examining the risk factors, we can begin to build in the double-checks that save lives: our patients’ and our own.

The Culture of Infallibility
Brian Goldman, MD, an author and emergency physician at Mount Sinai Hospital in Toronto, Ontario, Canada, has made it his life’s mission to address what he calls the culture of infallibility. His TED talk is incredibly powerful, and I hope that watching it will inspire you to make changes that will help us all learn to thrive, not just survive, in our chosen profession.9 When I reflect on how I suffered after overdosing my patient early in my career, I wonder how much my burden would have been lightened knowing that others in my practice had made errors and that we were taking steps to prevent something similar from happening again. Being part of creating a system to decrease the risk of a medication error might have been a first step on the path to healing. As our profession battles the growing risk of suicide and the less extreme effects of the stress we face daily, we can begin by being brave enough to have difficult conversations with our teams and with our clients.

I challenge you to go back to your practice and ask yourself: “What can I do to create a culture of openness? How will I handle the situation the next time I or someone in my practice makes an error? What systems are in place now to prevent errors, and how are those systems being used? What new systems can I put in place to reduce the risk of error? How can I foster a nonjudgmental and safe environment in which others feel comfortable sharing what they see or think? What conversations will I have with my team?”

We can all contribute to making medicine safer for patients and practicing medicine safer for our own well-being.

 
Dr. Fineman is vice president of learning and development for Ethos Veterinary Health. Earlier in her career, she practiced as a private practice medical oncologist. She is an adjunct professor at Washington State University College of Veterinary Medicine, does communication skills coaching at Colorado State University, and serves on the ACVIM Board of Regents.
References:
  1. Makary MA. Medical error—the third leading cause of death in the US. Br Med J. 2016;353:i2139. doi: 10.1136/bmj.i2139 
  2. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Eng J Med. 2002;347(24):1933-1940. doi: 10.1056/NEJMsa022151
  3. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physician attitudes regarding the disclosure of medical errors. JAMA.2003;289(8):1001-1007.  
  4. Kachalia AKaufman SRBoothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010; 153(4):213-221. doi: 10.7326/0003-4819-153-4-201008170-00002.
  5. Mellanby RJ, Herrtage ME. Survey of mistakes made by recent veterinary graduates. Vet Rec. 2004;155:761-765. doi: 10.1136/vr.155.24.761
  6. Moore JBismark MMello MM. Patients’ experiences with communication-and-resolution programs after medical injury. JAMA Intern Med. 2017;177(11):1595-1603. doi: 10.1001/jamainternmed.2017.4002
  7. Haynes AB, Weiser TGBerry WR, et al. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf. 2011;20(1):102-107. doi: 10.1136/bmjqs.2009.040022. 
  8. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499. doi: 10.1056/NEJMsa0810119
  9. Goldman B. Doctors make mistakes. Can we talk about that? TED website.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that. Published January 25, 2002. Accessed December 13, 2017.


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