Making mistakes

Yesterday’s sunrise brought for me a mix of melancholy and ecstasy.  It rose over my favorite setting on the last day of my trip to the Ontario woods.  After finishing up my duties as camp doctor, my daughter, my sister and I hopped in a canoe and paddled out to the islands in the middle of the lake.

Sunrise over Tea Lake

My daughter led us around the islands, blazing trails in an uncharacteristically fearless fashion.  But we had an eight hour car ride ahead of us, and a boat to catch to take us to that car, so we paddled back to camp, caught our boat, and that was that.

Except I hadn’t really had enough.  Not far from the lake is a set of falls whose very sound can take me back more than twenty years to being young, strong, and surrounded by friends (and beer).  PalKid was a bit hesitant heading up the trail from the parking lot, but once we got to the top of the falls and the granite nooks and platforms, she thought it was nature’s own wondrous playground—and she was right.

In the car later, no longer able to find distractions to delay our departure from the north woods, my sister turned to me and asked, “So, as a doctor, are you ever worried that you’ll make mistakes?”

“No,” I answered, “I know I’m going to make mistakes.”

This is something other industries—such as airlines—have understood for decades.  Medicine is only starting to learn what this means. Throughout our training, we are taught over and over to double and triple check our work.  We devote hours and hours to memorizing drugs and their interactions.  But we aren’t taught how mistakes really happen, or even that they do.  But what is made clear to us is that mistakes are not inevitable, are a sign of personal failure, and that only our own actions can prevent them.

It is certainly true that my own behavior can prevent or contribute to errors, but that is terribly simplistic.  Sticking with the example of drug prescribing, I may know hundreds of drugs, their effects, and their interactions, but why should I rely on the memory of a single individual when technology has existed for years to make this process safer?  My electronic health record (EHR) will check a drug prescription against the patient’s current drug list, allergies, and medical problems and warn me about potential problems.  I have no pride in this regard.  I’m glad I can remember these details most of the time, but every time my EHR reminds me of a potential drug interaction, I thank it silently, on behalf of myself and my patients.

Physicians are trained to work and think independently.  We aren’t yet trained to understand that medicine is too complex for any of us as individuals to avoid every error.  We are punished arbitrarily for our mistakes by a tort system that understands medicine the same way that we do, as a group of potentially-infallible individuals who screw up, rather than as a members of a system that is prone to error.  This not only perpetuates the false idea that errors can be eliminated through individual behavior alone, but prevents the systems changes that really can prevent errors.

20 Comments

  1. This not only perpetuates the false idea that errors can be eliminated through individual behavior alone, but prevents the systems changes that really can prevent errors.

    Word, Pal. We have this in so many areas where we insist on believing that personal infallibility (professional, ethical, etc) is the only relevant influence on behavior. We resist making systematic changes that can shape how populations of real people actually behave. It is maddening.

    One of my entry points on this is the issue of fraud and misconduct in science. While we persist in explaining fraud only as the act of an unethical scientist we avoid examining and fixing the systemic causes which modulate fraudulent acts. I think this is because our black/white brains assume that if we admit to systemic influences we are thereby excusing all personal failures. I say this is not so, and wish we could evolve to more nuanced views of professional behavior.

  2. Nice post. It’s strange that it seems that at least one television sitcom understands the inherent fallibility of doctors better than many in the system itself.

  3. DrugMonkey wrote: “I think this is because our black/white brains assume that if we admit to systemic influences we are thereby excusing all personal failures.”

    Well put. The same sort of bias arises in discussions of all sorts of criminal activity*, such as the Columbine shootings and even 9/11. After 9/11, lots of people were enraged by the suggestion that U.S. policy might have been an enabling factor in the attacks, as to them it seemed to be excusing the attackers. I feel quite comfortable freely regarding the attackers as amoral scumbags while at the same time trying to understand how world perception can make it easier to grow such scumbags.

    * Not trying to compare doctors to criminals here; just a similar psychological phenomenon!

  4. Dianne

     /  August 8, 2010

    Any chance of getting this post published somewhere that it’ll get a wider audience? You’ve outlined very eloquently what is probably* the worst problem in medicine today. Naturopaths and other wooists are fond of quoting studies talking about how many people are killed or harmed by medical errors and, of course, malpractice lawyers love medical errors, but very few people have, as yet, looked at how to really prevent errors. Even if punishing individuals did work (and I have serious doubts), the punishment (ie lawsuits) is applied so randomly that it is probably completely ineffective at removing error from the system as a whole or even removing bad doctors.

    *Though a strong argument could be made for the worst problem being the current health insurance system.

  5. D. C. Sessions

     /  August 8, 2010

    The bang-head-on-wall aspect of this is that we’ve had a rigorous quantitative understanding of systemic errors for longer than most MDs have been practicing. One of the most basic aspects of it goes back to something like Shannon’s Theorem: you can reduce errors out of a process to arbitrarily low levels, but insisting on zero errors at any given step is nearly the worst way to do it.

    http://en.wikipedia.org/wiki/W._Edwards_Deming

  6. Christina Pikas

     /  August 8, 2010

    We had a presentation at work at a colloquium from a doctor and one of the things he talked about was rehearsals and checklists. Coming from Navy training as I do, I assumed there would be a lot of simulations, practicing and checklists, but apparently it’s not so widespread in medicine. Good post.

  7. I don’t talk about it much, because it’s too delta from my sci-blogging identity, but I am a licensed private pilot, and learned the necessity of checklists as part of my training. My husband is an avionics engineer, and used to do human-factors research in cockpit design. Checklists, simulations, and train, train, train are something we both take for granted. It’s continually bizarre to me, as someone who writes about medical error and hospital infections, that medicine still hasn’t gotten there.

  8. Alex Besogonov

     /  August 9, 2010

    Wow. I never thought people in medicine still rely only on personal skills to minimize errors.

    I guess, being a software developer quickly cures one from assuming that personal infallibility is a good way to write good programs.

  9. Dianne

     /  August 9, 2010

    Checklists, simulations, and train, train, train are something we both take for granted.

    I’m not sure checklists are the answer, at least not the only answer, to medical error. Checklists are best for tasks which are relatively homogenous and linear. Medicine is often not. Similarly, what should we be simulating? ACLS simulates revival after cardiac arrest, but that’s a rare event for non-intensivists. Training is ongoing and continuous, I really don’t see how more time can be spent on it without decreasing patient care time. So while I agree that medicine needs to be more like aviation, I don’t think that the model used in aviation can be transfered unaltered to medicine.

    • DaveH

       /  August 9, 2010

      As another licensed private pilot chiming in, I can see how checklists might not always be appropriate in medicine.

      My thought is about the “no-fault” reporting of problems. If you see a problem, or make a mistake, you can report it without fear of repercussion. In medicine, I imagine the ingrained fear of malpractice suits (especially in the US, but other Western countries as well) would make that difficult. What would the medical professionals in the crowd say?

  10. I must agree with DaveH. Something must be done in the US about frivolous malpractice lawsuits. I am not in the medical profession. On the contrary I have been a patient most of my life. I have had good doctors and bad doctors. Even the good doctors made mistakes. Not once did I consider suing them for malpractice. The so-called justice system in the US is broken. It is driven solely by greed. Until the lawyers income from these suits is limited, doctors will live in fear.

  11. Vicki

     /  August 9, 2010

    I gather that checklists are useful in medicine for the same reason they are in other fields: they help make sure that you don’t omit ordinary, necessary tasks. A checklist isn’t going to solve a difficult diagnostic problem, but it can help ensure appropriate sterile procedure in an operating room.

    I’m a book editor. We have checklists at certain stages. They won’t ensure that the book is well written, or give me Super-Proofer who never misses a typo, but they’re useful in making sure we check the ISBN and other important but boring things, and that typos are fixed once caught.

  12. physioprof

     /  August 9, 2010

    This not only perpetuates the false idea that errors can be eliminated through individual behavior alone, but prevents the systems changes that really can prevent errors.

    Double-word. I hope you will forgive me for posting a link to one of my old posts that touches on one particular systemic issue that leads to significant amounts of medical error:

    http://physioprof.wordpress.com/2008/12/13/korean-airline-pilots-arrogant-physicians-and-life-or-death-decisionmaking/

  13. To add to DaveH (how do you quote in these comments, anyway?): I think the issue in medicine isn’t just revealing error to someone outside medicine, and being sued for it. The larger issue is the inability of medicine to come to grips with the power differential among staff within, for instance, an operating room,so that staff of lesser status feel too intimidated to correct a more senior person.

    Peter Pronovost MD of Hopkins (the “checklist guru” MacArthur fellow) tells an apposite story of trying to get a surgeon to stop and change gloves in the OR because, as anesthesiologist, he was detecting the signs/symptoms of a profound latex allergy; the surgeon refused until Pronovost walked to the OR phone and dialed the mobile number of the hospital CEO, who had distributed it as part of a medical-error reduction program. (At which point, as Pronovost tells the story, the surgeon stripped off his gloves, threw them at Pronovost and walked out of the OR.)

    Following the Tenerife crash, aviation dealt with latent intimidation-by-status by instituting Cockpit Management Training (CMT), which emphasizes the prerogative of anyone in the chain of command to speak up in case of perceived error. (A resource on CMT, not that long post-Tenerife:
    http://www.crm-devel.org/resources/paper/diehl.htm )

    To my eye, medicine could use a similar program.

    • Dianne

       /  August 10, 2010

      One question that this anecdote brings up to me is why did the surgeon behave that way? Simply because he was an arrogant jerk? If so, probably not much to be done about it. But could there be some other underlying problem that led to this behavior? I’m less rational when tired, maybe he had worked too many hours or been overly stressed. (Note: this is NOT to excuse the surgeon’s behavior: it was inexcusable no matter what the situation. The question, IMHO, is whether any systematic changes can be made to decrease the probability of surgeons and other doctors-and nurses, respiratory techs, etc-from acting this way.)

  14. physioprof

     /  August 10, 2010

    The larger issue is the inability of medicine to come to grips with the power differential among staff within, for instance, an operating room,so that staff of lesser status feel too intimidated to correct a more senior person.

    This is exactly the topic of the post I linked above.

  15. In the Keystone program, nurses are specifically empowered to stop a procedure if the checklist is not properly completed (assuming a non-emergent situation). This only works if the administration backs the nurses.

    • Pronovost spoke at the AHCJ conference this past year. During Q/A, a writer who is also an RN stood up and asked about just that issue. Paraphrasing (but not by much), she asked: “The surgeon I criticize brings money to the hospital. As a staff member, I am an expense. Who do *you* think they will back?”

  16. There’s a line from the “House MD” episode “Three Stories”, which I’m sure you know. It runs something like: “Sooner or later you will screw up, and you will kill someone. If you can’t live with that, find another profession.”

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