Facing our mistakes

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Facing our mistakes

• Introduction
• A group of medical students at our home several
  years ago.The theme for the evening was, yes
  Facing our mistakes.
• The tension between being an unfailing doctor
  and the uncertainty of medicine!

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Facing our mistakes

• Definitions
• Not about
• Side effects/non-preventable complications
• But
• Human error in medicine
• or
• Mistakes
• The cause of the events
• System/organization
• Health care person(the naming/shaming and
  blaming culture)

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Facing our mistakes

• History
• 400 y BC. Primum est nil nocere Hippocrates
• 1979 Forgive and remembermanaging medical
  failure. Charles Bosk.
• 1984 NEJM.Facing our mistakes by David
  Hilfiker.
• 1999 Institute of Medicine, USA, published a
  reportTo err is human.
• 44 000 - 98 000 deaths pr year in somatic
  hospitals due to errors!

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Facing our mistakes.

• The magnitude of the problem
• Several studies in somatic hospitals shows
• Advers events or mishaps 10
• Deaths among these 5
• Preventable 50
• No figurs from GPs,psychiatry and long-term care
  facilities.

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Facing our mistakes

• The magnitude of the problem
• But the subjective experience is so different!
• Some of us are vulnerable, some of us are more
  robust!
• The main problem, subjective, could often be our
  feeling of guilt

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Facing our mistakes

• The consequences
• The patient
• Dead 5
• Disability 10
• The second victim -doctors/nurses
• The third victim -relatives to the pats
• The fourth victim -health system

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Facing our mistakes

• Why do errors happen?
• The old way
• It is due to one person the bad apple
• The new way
• It is due to the system, procedures, the way we
  organize our health service.

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Facing our mistakes.

• More about causes in details
• -failure in the medical decision/ reasoning
• -failure in doing a procedure, say an operation
• -failure in the technical equipment
• -failure in the systems/organization/lack of
  guidelines

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Facing our mistakes

• What can go wrong in medicine?
• Nearly all things can happen!!
• The woman and an injection with streptomycin in
  1966.

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Facing our mistakes

• Grouping the adverse events/mistakes
• Adverse Drug Events
• A patient with multiple myeloma, 1994
• Hospital Infections
• Falls
• In surgery
• In anesthesia
• Radiotherapy
• And so on

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Facing our mistakes

• How do we manage our mistakes?
• A young man -about 40 y- with a high grade
  lymphoma, to-day probably called diffuse large
  B-cell lymphoma.

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Facing our mistakes

• 1981 I worked at the Norwegian Radium Hospital
  as a trainee in oncology. I started there in 1977
  and in 1981 I worked in the lymphoma-group as a
  junior doctor.
• The patient was a man, about 40 y old, married
  with 2 or 3 children. DiagnosisHigh-grade
  malignant lymfoma. Stage? Treatment
  6 courses with chemotherapy and then
  radiotherapy to his neck/supraclav regions and
  upper mediastinum(?).

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Facing our mistakes

• Few months later he was readmitted with lymhoma
  relaps? He had a diffuse subcutaneous tumor
  located to his neck/supraclav and as far as I
  remember in the upper mediastinum.
• We decided to re-irradiate him.I discussed him
  with the physicists and we made a very elegant
  dose-plan

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Facing our mistakes

• I presented the dose-plan at a doctor-meeting and
  they all thougt it was well done- though it
  seemed to be a little sophisticated(?).
• The patient sat outside the meeting-room ,but
  they didnt ask to see him!! Why didnt I present
  the patient for my colleagues??

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Facing our mistakes

• The patient got the planned radiotherapy and went
  home.
• He and his family lived not far from my parents!

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Facing our mistakes

• Some few weeks later I got a call from a doctor,
  working at the local hospital to which the
  patient belong. The doctor told me that the
  patient was admitted to the hospital with great
  respiratory problems due to what they thought
  tumor progression around trachea in the neck
  (and in the upper mediastinum?)!
• I felt a rising panic in my body
• I had re-irradiated a subcutaneous fibrosis
  induced by the first radiotherapy we gave!
• In a moment I understood the clinical picture!

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Facing our mistakes

• I discussed this with the doctor at the local
  hospital, but he was convinced that the patient
  had a lymphoma relaps. He was not familiar with
  irradiation fibrosis!
• After some few weeks the patient died.
• No autopsy was performed?
• Then followed months with self-reproach/blaming
  myself, speculations and insomnia, etc!!

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Facing our mistakes

• What I did
• I called the patiens wife and as far as I
  remember, I mentioned to her that the tumor
  that gave her husband respiratory problems was
  induced by the last radiotherapy.
• I cant remember if I talked to one of my
  colleagues, at least immediately.
• After 1-one- year I got courage to
  introduce/discuss the whole story at a
  doctor-meeting!

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Facing our mistakes

• Second thoughts
• The crux of the matter what had happened if I
  had presented the patient for my colleagues when
  we discussed the dose-plan?
• Why didnt I present the patient?
• Where was the head of the lymphoma group?
• Would a different treatment have saved the
  patient?
• No autopsy that means that there is a tiny
  little chance that it was lymphoma relaps and not
  oedema/fibrosis they diagnosed clinically and by
  CT-scan.

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Facing our mistakes

• More seconds thoughts
• How to deal with my guilt?
• My broken image!
• The doctors are perfect! They do always the best
  for the patients!
• The climate of medical school and recidency
  training, for instance, makes it nearly
  impossible to confront the emotional concequences
  of mistakes.(D.Hilfiker)

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Facing our mistakes

• The wrong way to go
• Try to hide! As in Genesis 3.chapter!
• Silence!
• Try to forget
• Move to another geografic area, enter another
  speciality try to escape!
• It is a heavy burden to bear!
• Our clinical initiative and learning processes
  become impaired.

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Facing our mistakes

• A better way
• Be honest
• Seek for help, immediately if necessary.
• Report to your chief and write a note in the
  patients journal.
• Meet the patient or his relatives and tell them
  the truth and apologize.
• Ask them to forgive???
• Meet the other persons involved in the event and
  go through the story, step by step.
• A report to the hospital commitee for adverse
  events

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Facing our mistakes

• A better way cont
• Discuss the event with your colleagues in a
  meeting with the heading
• Why did it go wrong?
• Present the history and discuss the medical
  problems, how you thougth,why you did so and so.
• As you do this, you deal with your emotional
  reactions!
• Try to learn for the future.
• Forgive and remember!

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Facing our mistakes

• Who could be better prepared for openly
  discussing our mistakes than a christian doctor?
• We have a God that have mercy with us!
• We can trust in God and Jesus and can openly tell
  them our shortcomings.
• Nevertheless it is difficult!

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Facing our mistakes

• Complaints and compensations.
• In Norway Norsk Pasientskadeerstatning(NPE)
  since 1988. That means Any patient that is
  harmed when in contact with the health system,
  can complain and his story will be judged by NPE.
  Aproximately 30 get compensation
• In USA. You have to go to the court to get any
  compensation. They call it Tort cases.

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Facing our mistakes

• Prevention
• An open milieu among doctors and nurses.
• More focus on the system, rather than the single
  person (bad apple).
• National, systematic reports Every defect (is)
  a treasure learning from adverse events in
  hospital.
• Look to the aircraft with their Aviation Safety
  Reporting System (non-punitive).

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Facing our mistakes

• At some point we must bring our mistakes out of
  the closet. We need to give ourselves permission
  to recognize our errors and their consequences.
  We need to find healthy ways to deal with our
  emotional responses to those errors. Our
  profession is difficult enough without our having
  to wear the yoke of perfection
• David
  Hilfiker