Making Mistakes Meaningful

Making Mistakes Meaningful

S**t happens. As inevitable as death and taxes people, regardless of their job, make mistakes. And yes, that includes doctors. What people find very hard to take, doctors included, is the consequences. You want everyone thinking right, acting right and treating your dad/mum/sister right. But, sadly, that can’t always happen.
A lot of research into medical errors is floating around online, and two points come up over and over again. 1) most mistakes are not due to lack of knowledge and 2) somebody somewhere in that patients pantheon of carers knew a mistake was being made in nearly every case.
For example, a completely hypothetical made up fully non-real doctor A sees an equally imaginary not based on any reality whatsoever thirty year old woman with a headache. She looks well. He looks her over, finds nothing, and sends her home. She re-presents to her GP three week later with worsening headache, and blurry vision. She is rushed to hospital where a new doctor, doctor X, finds she has swollen optic nerves (the nerves that carry information from eye to brain and can be seen at the back of the eye) and needs emergency treatment to avoid going blind. Luckily, she is treated and is fine. She goes away happy, doctor X is happy, doctor A is on leave and really happy. Everybody wins yes? No.
A made up amount of time later doctor A sees another young patient with a headache. Having learnt nothing from his previous similar patient he sends him home without checking his eyes. He goes blind and sues everyone involved. And rightly so.
Simple answer isn’t it? Sack doctor A. No.
I must stress I have completely fictionalised the above- I can’t and wouldn’t use even an anonymised real story. But the point I’m trying to make still stands; mistakes happen. That in itself is not a crime but when we don’t learn anything from it, IT IS. Fool me once, shame on you Idiopathic intracranial hypertension (the condition in both stories), fool me twice, shame on me. And a GMC review.
There’s always a lot of talk about eliminating human error in medicine like with the aerospace industry. But the comparison isn’t really fair.
Plane goes up, adjusting for a known number of measurable variables, plane stays up, plane comes down. Years of training, careful checklists and clever thinking have gone into minimising sheer human stupidity to the point that flying in an airplane is far safer than crossing the road, or riding a horse, or eating a steak. So why can’t we do the same?
If medicine were really like an airplane, the plane may or may not go up, depending on the planes beliefs about Western flying, dislike of the airport and how much the plane really wants to fly. Adjusting for an infinite number of unknown and mostly unmeasurable variables, the plane may stay up, it may decide it wants to go home, fly higher, lower or may find it suddenly hasn’t got the fuel and crash. The plane may land, as long as the pilot has managed to build a personalised runway, the plane really wants to land, and the other planes are happy to look after it. All the while the pilot is actually six different pilots who change places every 8-12 hours and are also flying twenty other planes at the same time.
Despite a rather long and tortured analogy my point is human error exists on both sides of the equation. But there ARE simple things we could do to make mistakes positive.
Some places may be better than others but feeding back major errors should be systematic and standardized. In the age of electronic notes every professional involved at any point, in any death, major error or Complaint could be automatically notified. Teams should be responsible for not just discussing one or two cases at mortality meetings but all of them- with the doctors involved. And the practice of corporate branding and cover-ups and gagging whistle-blowers* should be hunted out and destroyed.
Preventing mistakes is as important. Proper medicine is boring. House is an awful doctor- he never sees the patient, he orders every test and treats everything, and is about as thorough as a toddler on haribo and speed. You have to be methodical, thoughtful, careful and most importantly systematic.

To quote the great Mr Twain ‘Its not what you don’t know that gets you into trouble.It’s what you know for sure, that just ain’t so’.

And what you know for sure tends to be what you should question the hardest, as this is where mistakes are hiding.
Ultimately with so much swirling around the medical ether currently about whistle blowing, medical errors and patient harm we need to step up and grow as a profession. Yes we make mistakes, but the argument shouldn’t end there. The definition of madness is often touted as doing the same thing over and over and expecting a different result. If we do not take steps to seek out and feedback failures we are dooming each other to insanity. Or something.
THE LEGAL BIT- all situations discussed above are not based in any way on any real patient. Also I am not advocating giving speed to toddlers. Or haribo really. It is very sugary.
*True whistle-blowers with legitimate concerns about patient safety, NOT Daily Mail writers.

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