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Why residents should 'fess up to their mistakes

Errors provide an opportunity to learn—if handled the right way

From the December 1996 ACP Observer, copyright 1996 by the American College of Physicians.

By Christine Wiebe

One resident admits that she once inserted a central line into a patient's carotid artery by mistake. Fortunately, a nurse caught the error before the patient was harmed.

Another housestaff team failed to recognize that a patient's shaking was due to alcohol withdrawal. That patient died before receiving appropriate medical treatment. Illustration by Roger RothYet another resident recalls how she inserted a nasogastric tube into a patient's nostril, only to see the end come out the other nostril, drawing gasps from medical students who were observing.

Such stories are far from rare, yet many residents are reluctant to admit their mistakes, out of fear of a reprisal from educators or legal action from patients. But educational experts say that by coming forward and talking about errors, residents can learn valuable lessons and possibly avoid making the same mistake twice.

Facing the music

Some say that residents are reluctant to admit to errors because training programs discourage it. As one resident explained, "At the premiere teaching programs in the country, they like to believe their residents never make mistakes."

In fact, a study on housestaff mistakes published several years ago found that nearly a quarter of the residents interviewed felt inhibited by their training programs from discussing errors. And it hasn't improved, according to Albert W. Wu, ACP Member, author of the study and associate professor of internal medicine and health policy and management at Johns Hopkins University. He explained that, despite growing recognition of the problem, "the pressures that prevent these things from surfacing have not gone away." For example, Dr. Wu added, housestaff often must report errors to the same people who will write their recommendation letters.

But hiding mistakes not only increases residents' anxiety, it also reinforces the notion that errors don't happen. "If no one's sharing mistakes, everyone decides that either nobody makes mistakes, or that something really terrible happens if you do," explained Camilla S. Graham, ACP Associate, a third-year internal medicine resident at Boston Medical Center.

Instead of covering up mistakes, educators agree that residents should inform the attending physician and program leaders. Then, either the resident or the attending should tell the patient what has happened.

Residents who disclose a mistake to a patient should not necessarily worry about being sued. Lee J. Dunn Jr., LL.M., a Boston attorney who specializes in malpractice litigation and is a member of the ACP Ethics and Human Rights Committee, said that in general, residents are legally liable only for behavior that is deemed to be outside the norm for other physicians at the same level of training. In the majority of cases, he said, residents should not be afraid to admit their mistakes.

And though residents probably won't be held legally liable for making a mistake, Mr. Dunn advises that they inform patients of any errors themselves. Not only is it the ethical thing to do, he explained, but it is a smart move in avoiding malpractice litigation. "The patient who understands that you're being open and honest is the one who likely won't sue," Mr. Dunn said.

Talking it out

To encourage more residents to talk about their mistakes, educators are rethinking how errors should be reported—and what programs should do with the information. Earlier this fall, for example, organizations including the American Medical Association and the Joint Commission on Accreditation of Healthcare Organizations sponsored the first-ever national conference that focused on housestaff mistakes. Experts say the meeting was significant because it was one of the few times that the profession has publicly discussed the topic of clinical mistakes.

Bertrand M. Bell, FACP, a professor of medicine at Albert Einstein College of Medicine in New York City who is best known for heading the New York commission that proposed limits on residents' work hours, said that training programs must first establish an environment that prevents mistakes from occurring. "Residents should be taught to be comfortable with the idea that they will often be in situations where they don't know something, and if they don't know, they're supposed to ask," he said. Training programs need to remove any suggestion that asking questions implies an inferior grasp of the information, he added. "As a PGY-41," he said, "I'm always asking."

There's also evidence that a little encouragement can go a long way. A study in the August Journal of General Internal Medicine found that streamlining the process for reporting mistakes encouraged housestaff to report "adverse incidents."

At the Denver Veterans Administration, for example, educators circulate a clipboard during morning report for residents to list adverse events. "There are so many demands in a busy resident's schedule that if you don't make it an easy thing to do, people won't report [errors]," said Carolyn H. Welsh, FACP, lead author of the study and a staff physician at the Denver VA Hospital.

Some programs are finding that the best way to get residents to come forward is to emphasize the potential for learning. At the University of Texas Health Science Center at San Antonio, housestaff errors are examined at weekly morbidity and mortality conferences. Eric W. Leong, ACP Associate, chief resident in internal medicine, explained that the conferences examine cases in which mistakes significantly affected patient health. Individuals involved in the cases are protected by anonymity.

Residents aren't the only ones who can learn from housestaff mistakes. At the Denver VA, residents talking about mistakes alerted educators to the fact that patients were not receiving antibiotics in a timely way. As a result, program officials examined the entire process, from when the resident wrote the order to when the medication was administered, and made the necessary changes.

Dealing with mistakes may also help prepare residents for practice in the real world. As physicians at all levels come under closer scrutiny from managed care organizations, Dr. Welsh said, facing clinical errors—and learning from them—will be increasingly important.

Coping with guilt

Talking about errors can also help housestaff deal with the guilt that they often feel after making a mistake.

When Dr. Bell was an intern, for example, he was instructed to administer an injection to a critically ill patient over a period of 15 minutes. He took out a stopwatch that he had received as a gift and began watching it closely. "I was focused exclusively on looking down and making sure it was being injected slowly," Dr. Bell recalled. "When I looked up, the patient was dead."

The incident led to much soul searching. Family and colleagues reassured him that the patient had been very ill and might have died regardless of his actions. Four decades later, Dr. Bell has made peace with himself about the incident, but noted that "to this day I can still see the whole thing."

That reaction is fairly common, according to Patrick M. Dunn, FACP, assistant director of the Portland Program in General Internal Medicine at Legacy Portland Hospitals in Oregon. Several years ago, he participated in a research project that examined the emotional impact on physicians who believed they had made a clinical mistake. "Physicians could recall in exquisite detail how they felt, what the circumstances were and what others involved had thought" about the event, he explained.

Researchers with the project concluded that talking about errors is significant for two reasons. For one, perceived mistakes are often not considered a mistake by other medical colleagues, Dr. Dunn said. Plus, talking about an error can be cathartic. "Disclosure to a trusted colleague can be a very helpful part of the healing process," he said.

For now, however, medical educators who want residents to be more open about their mistakes need to set the stage for such admissions. "They need to make it clear that they fully expect that things are going to go wrong," said Dr. Wu from Johns Hopkins, "and when they do, they need to know about it."

Disclosing errors: ACP's view

Are physicians morally obligated to disclose errors to patients? According to ACP'as Ethics and Human Rights Committee, the answer is yes.

ACP's "Ethics Manual" says that physicians should "disclose to patients information about procedural or judgment errors made in the course of care, if such information significantly affects the care of the patient."

While the "Ethics Manual" points out that "Errors do not necessarily constitute improper, negligent, or unethical behavior," a case study on disclosing errors in the ACP book "Ethical Choices: Case Studies for Medical Practice" emphasizes that failure to disclose a significant error can be all three. The "Ethical Choices" book also contains another case study that focuses on when residents make mistakes.

ACP's "Ethics Manual" costs $10 for ACP members, $13 for nonmembers. "Ethical Choices: Case Studies for Medical Practice" is $25 for College members, $33 for nonmembers. To order a copy of either, call ACP's customer service department at 800-523-1546.

Christine Wiebe, of Providence, Utah, writes frequently on issues related to medical residency.

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