RP101 – Making Mistakes (Oct 2018)



Session Readings

 

Background  

We have often heard the phrase “everyone makes mistakes.” While this is readily accepted as fact in many fields of work, the field of healthcare has been much more reticent to accept this – the cost and consequences seem too profound, too high to let this be “allowed.”  Mistakes occur at a number of different points in the process of care,  to include diagnosis, treatment, and follow-up. A now famous report from the Institutes of Medicine, To Err is Human, describes error as a leading cause of death and disability in American medicine.   The first of these, diagnostic error, has been demonstrated to be made by providers 10-15% of the time [Elstein 1995].  In fact, a report from 9/2015 by the Institutes of Medicine (IOM) entitled “Improving Diagnosis in Healthcare” concludes that most of us will experience (as patients) diagnostic error at least once in our lives, some of which will have catastrophic effects. Errors in treatment to include medication and surgical errors are equally concerning and an important area of focus in the quest to improve the quality of care we deliver.

While we endeavor to reduce mistakes in healthcare, the fact remains that each of us will make mistakes in the course of our practice. In this session, we are not focused on how we will avoid mistakes, but how we have reacted when we have made mistakes in the past and whether these reactions have impacted our actions in ways that compound or mitigate these mistakes. I want you to consider whether or not your experience making mistakes (of any sort) can help to prevent subsequent mistakes, or at least give you a framework for how to manage your feeling about mistakes.

In the past, some students have expressed the belief that providers only have strong reactions to mistakes that result in a “bad outcome”.  Experience demonstrates otherwise;  our reactions to mistakes – or near mistakes –  can be quite powerful and long-lasting, whether or not the mistake results in a “bad outcome”. Feelings of guilt and shame often pervade the experience, influencing us in myriad ways that can impact the way we treat our patients. We also know that poorly resolved mistakes in healthcare contribute to decreased provider satisfaction with their chosen profession, an increased rate of attrition from the profession, and increased rates of suicide.

I am interested in how our tendencies towards perfectionism as health care providers play into this narrative. Not all perfectionism is created equal. Striving for excellence is not inherently a bad thing, but when we start to feel like we are a failure, versus we have experienced a failure, we sometimes have difficulty moving forward. How we have been conditioned around this idea is part of our personal context. Some of us have experiences making mistakes as members of the healthcare team; others have not. Regardless, each of us has experiences making mistakes. The way we react both to our own mistakes (and to a degree, those of others) has implications for how we will cope with our own mistakes as healthcare providers and thereafter care for our patients.

Assignment

***PAPER IS DUE OCT 25 AT 1200****

Reminder: When submitting your paper, please:

  1. submit on Sakai in Word format
  2. include your email address in the header
  3. include your last name in the file name 

As with previous sessions of Reflective Practice, you will write a reflective paper in the R.S.I.P. format and participate in small group discussion in order to achieve the below objectives.


Objectives

By the end of this session of Reflective Practice, students will demonstrate the ability to:

  • Reflect on mistakes they have made during their lives and potentially early medical careers
  • Listen to narratives about others’ mistakes and reflect on how they think about others’ mistakes vs their own
  • Identify their reactions to making their own mistakes and the sources of those reactions
  • Explore how those reactions impacted the care they delivered or could impact the care they deliver
  • Analyze strategies for coping with mistakes in the future.
  • Discuss guilt, shame, perfectionism, and self-compassion as themes in error and in resilience after error.
  • Illustrate both effective and non-effective ways of communicating mistakes

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R.S.I.P. Guidelines

SPECIFICS:

Reaction

  1. Identify one or more reaction(s) you have to the panel narratives.
  2. Identify one or more reactions you had to the resources as they pertain to mistakes in healthcare.

Sources –  For your reactions,  reflect and write about the source of your reaction Be specific.  The sources of these reactions may include:

  • your own experiences making mistakes
  • feelings of guilt and/or shame as they relate to mistakes
  • how you perceive yourself before and after you have made a mistake
  • how you perceive mistakes to be viewed in:
    • your family or origin
    • the community in which you grew up
    • the military community
    • the medical community

Implications: for each reaction, identify the positive and negative implications your reactions have for patient care.

Plan:  This is your opportunity to essentially reflect on your reflection. Try to be specific and realistic. For example, writing, “I will give every patient a survey at the end of every visit and spend 3 hours reviewing the results and contemplating their meaning,” is not realistic. Similarly, planning to journal for 2 hours per night is likely not realistic either.

Realize that you may not feel like there is a change to make for every reaction, but try to pick at least one lesson learned and formulate a plan for change for the future.

As you think about your reflection above, what have you learned about yourself? What would you change (if at all)? And how? How might you approach similar patients or challenges in the future? What question would you want to bring to the group discussion to further explore?

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Panelists

Capt Diana Costa, USAF, is a class of 2020 DNP candidate.

Dr. Eric Marks, CAPT (ret), is a professor of medicine and professor of preventive medicine and biostatistics at USUHS.

Ms. Barbara Moidel is the director of Healthcare Resolutions for the Defense Health Agency, and has been helping to improve transparency and mistake communication for the military for the past 18 years.

 

tedmed_wh_rgbConfront harm and prevent medical casualties (~10min) - LtGen Horoho Patricia Horoho, retired Lieutenant General in the U.S. Army and the first woman and first nurse to serve as the Army’s Surgeon General, reveals how healthcare can cause harm by sins of commission and omission.
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New York TimesMy Human Doctor Medical school teaches us to examine, to research, to treat. We don’t learn to err and recover.
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New York TimesMy near miss A doctor relays a close call with a patient's diagnosis...the "near miss" - a mistake that could have cost the patient serious harm, but didn't.
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TEDxBrian Goldman: Doctors make mistakes. Can we talk about that? What’s an acceptable “batting average” for a physician? Brian Goldman examines the paradox of perfection in medicine, starting with three little words all physicians dread.
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New York TimesThe Many Errors in Thinking About Mistakes by Alina Tugend Children learn that ‘everyone makes mistakes’ as a crucial part of the learning process, but are rewarded for getting the right answer. A NY Times columnist explores society’s paradoxical approach to making mistakes.
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The New YorkerFailure and Rescue by Atul Gawande The difference between good and great healthcare is not fewer mistakes, it is more rescues.
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TEDxTransparency, Compassion, and Truth in Medical Errors Leilani Schweitzer's son died by fault of medical error - she talks of the importance of transparency, truth, and compassion in medicine.
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Session originally created by: Adam Saperstein | SOM/GSN, Uniformed Services University | Director, Reflective Practice | Family Medicine