Human Error

No one in medical school told me about medical error and how to respond if a medical error was made.  I do remember the many presentations and “pep talks” about what an honor it is to become a physician and take care of a patient in need.  By the end of medical school I was ensured that I had received the necessary training and now had the knowledge to go out and treat people.

Now 1 1/2 years into my residency I do feel that I can manage my patients’ care very well at times.  What I didn’t expect was that despite my most compassionate care, errors have occurred that have affected, or come close to affecting, my patients.  I haven’t purposefully tried to cause harm to my patients.  My attendings haven’t tried to harm their patients on purpose.  The nursing staff has not purposfully tried to cause harm to their patients.  But despite our good intentions, error does happen.  Luckily, most of these errors are “near misses” where the error is caught before it reaches the patient and there is no actual harm done.

One of the most concerning issues is not necessarily the error in and off itself, but how our system responds to the error.  It is our natural human instinct to want to blame someone else for a mistake and absolve ourself of any involvement.  “If only we educate this one person who made the mistake than we have solved the issue and can forget about it.”  This is the wrong thought process entirely.  As I said above – no one goes to work intending to cause someone harm or put a patient’s safety at risk.  Usually when there is an error, there is a reason that the error was made and a high likelihood that a similar error will be made in the future.  A better response to error is to seek out ways that the error could be made in the future.  When we focus on the shame and blame game, we create an environment based on fear and the teamwork necessary to provide good and safe patient care is challenged.

I am lucky to be a part of a residency program that has a focus on patient safety and error reporting.  Our faculty provide a very welcoming environment to discuss these events and work as a team to create ways to prevent these events in the future.  We are working to help create a medical environment that involves open and honest communication with all of the staff of the hospital as well as our patients.  As much as I would like to think that I can be that unflawed and all-knowing physician that medical school pushed me to become, I can’t.  Good medicine involves open communication with the nurses, staff, and patients to ensure appropriate and safe care is given.  If we are not willing to have these conversations, we can only hope for more of the same mistakes in the future.