If you’ve been practicing long enough – as a nurse, a nurse practitioner, a physician, or a physician assistant, you’ve made a medical error – whether you’re aware of it or not. And that’s perfectly normal!

An abundance of research has focused on ways to reduce medical errors, but there has been less emphasis on the second victim: the clinician who makes the error (1). We all know errors are common in the practice of medicine, as there are inherent difficulties in the diagnostic and treatment pathways, independent of type of training, technological advances, or safeguards in place (1).

Why do we make errors?

There are many reasons why diagnostic errors happen. Four common sources of error have been studied:

1) Wrong synthesis: lack of knowledge about a disease leading to the wrong conclusion;

2) Premature closure: not all disease processes were considered, a highly prevalent error;

3) Inadequate synthesis: data does not support the conclusion; and

4) Omission: missing important information that could have led to a correct diagnosis (2,3).

To confirm or refute a diagnosis, we have to synthesize information from the history, the physical exam, and potentially order additional tests that are not 100% accurate (1). Then we must clinically correlate the results of these tests to ensure appropriate interpretation and distinguish between disease patterns that have similarities. We are taught in multiple choice, that there are “right” and “wrong” answers, which simply does not prepare us for the blurry nature of clinical medicine. The higher order thinking required for diagnostic reasoning is highly fallible, given we simply cannot obtain all the knowledge that may be required to make a diagnosis (1). Further, we may or may not be aware of the cognitive biases that can get in the way of getting to the right answer.

We know errors happen – we read about them in the news, we hear about them from colleagues. Do we like to talk about the errors that we make? The things that we miss? Of course not. There is an innate culture in the medical profession that we should be perfect – patients are counting on us; their lives are in our hands. This culture is completely opposite to the well-known fact that humans are not perfect, that errors are a part of life, and therefore are a part of medicine.

Several studies have been published on the ubiquity of mistakes in clinical medicine, yet there is no consensus on the need for us to be trained on how to manage the emotional burden that mistakes can have on our conscience (1). The emotional response from a medical error can last days to years; we may feel guilt, fear, anger, embarrassment, even humiliation (4); we may bear the burden of our mistakes and live in isolation. Further, when errors happen, we are more prone to experiencing imposter syndrome (where high achieving individuals fail to internalize accomplishments and experience self-doubt and fear of being exposed as a fraud or imposter) (5).

How do we deal with medical errors?

Thankfully, there has been increased awareness and interest in how to help clinicians process and manage medical errors.

1. Acknowledge: As Dr. Hilfiker, a family physician back in 1984 wisely emphasized, the ability to acknowledge an error is the first and most critical step in the healing process – both to oneself, and to the patient involved (4). 

2. Analyze – but not for too long! The process of analyzing the mistake intellectually, with a trusted colleague or mentor, can help us learn from the mistake and implement solutions and strategies to reduce similar errors in the future. What can we learn to prevent future mistakes?

3. Move on (possibly the most important step): Once you’ve acknowledged the mistake, identified actions that may have led to harm, and have done your best to right any wrongs, it’s imperative to move on. Dwelling on the past, as we like to do as perfectionists, is counterproductive, and can lead to more mistakes (6). It can set us up for cognitive biases like the affect heuristic (relying on our emotions to make decisions) or the availability heuristic (thinking of things that recently happened) which is unhelpful in the diagnostic pathway. Often our actions are not the root cause or the only cause of the patient’s outcome, yet we can still find ourselves in the endless analysis loop – fixating on what went wrong, what we did wrong.  At the end of the day, dwelling on the past will not fix the present circumstances.

Some other points to keep in mind

We do not give our patients diseases; we do our darn best to prevent harm and hope for the best possible outcomes.

You came into the profession wanting to do good – remind yourself of that.

Our actions are (usually) not the sole reason why something bad happens – in fact, we often have little control over patient outcomes because there are so many other factors that contribute.

It is absolutely necessary that we can work in environments that allow us to make mistakes, to debrief in a constructive and healthy way, and to learn from mistakes. Being able to openly acknowledge and share our mistakes will help us grow and evolve, as people and as professionals. We become clinicians to help people, to harm someone is unimaginable (6). We hope we won’t make errors, but we have to assume that we will – as humans we need to understand our vulnerability to error and must be willing to grieve when we make a mistake (6). Doing anything different may lead to harsh emotional impacts, isolation, and burnout.

At the start of our training as nurses, nurse practitioners, physicians, or as physician assistants, learning how to deal with errors should be integrated into curriculum and clinical rotations. It’s a vital part of the learning process and would better prepare us for the real-world emotional impact that mistakes can have on us.

We need to accept that medical errors are simply a part of our jobs and are as natural as the air that we breathe. We should be allowed to evolve and grow in our professions because of the mistakes we make.

Stay tuned for a future post on imposter syndrome – what is it, and how can we manage it?

Strongly recommended videos/podcasts (if you haven’t already tuned in!)

Doctors Make Mistakes. Can we Talk About that? by Brian Goldman: https://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that?language=en

The Second Victim (IM Reasoning): https://imreasoning.com/episodes/episode-10-second-victim/

References:

Goldberg RM, Kuhn G, Andrew LB, Thomas HA. Coping with medical mistakes and errors in judgment. Annals of emergency medicine. 2002;39(3):287-92.

Voytovich A, Harper I, Rippey R. Evaluating analytic reasoning in the management of the multiproblem patient: a system for attaining reliability and validity. Presented at: the Research in Medical Education (RIME) Conference of the Association of American Medical Colleges; November 1979; Washington, DC. 22.

Voytovich A, Rippey R, Suffredini A. Premature conclusions in diagnostic reasoning. J Med Educ.1985;60:302-307.

Hilfiker D. Facing our mistakes. N Engl J Med.1984;310:118-122.

Kolligian J, Jr, Sternberg RJ. Perceived fraudulence in young adults: is there an "imposter syndrome"? J Pers Assess. 1991;56(2):308–26.

Hazan A, Haber J. Mindful EM: Dealing with Mistakes and Preventing Regrets. Emergency medicine news. 2017;39(5):24-.