RP101 – Making Mistakes (Oct 2017)



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.

One model for thinking about how we make mistakes is proffered by Duke University. This site is rich with a simplified but very effective way of thinking about how errors in daily life and in medicine occur. They offer these as 3 basic categories for how mistakes are made:

  • Skill-based errors – slips and lapses – when the action made is not what was intended
  • Rule-based mistakes – actions that match intentions but do not achieve their intended outcome due to incorrect application of a rule or inadequacy of the plan.
  • Knowledge-based mistakes – actions which are intended but do not achieve the intended outcome due to knowledge deficits.

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, 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.

As we have discussed throughout Reflective Practice, our reactions (including reactions to mistakes) stem from 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) have serious implications for how we will cope with our own mistakes as healthcare providers and thereafter care for our patients.

One article to read ahead of time — we will discuss this one at the panel session: https://www.cochranfirmdc.com/wp-content/uploads/2014/05/FOX-5-Investigates_-Medication-mistakes-that-can-kill-DC-News-FOX-5-DC-WTTG.pdf 


Assignment

***THIS PAPER IS DUE BEFORE THE PANEL ITSELF…PLEASE NOTE THE DUE DATE!!!****

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. This paper is due BEFORE the panel and small group – based on your OWN experience w/ mistakes, and the resources provided. See Below for details.  


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
  • identify their reactions to those 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.
  • 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 had to a mistake you have made in the past. If you have a story related to medical care, all the better. If you can’t come up with one from your time in medicine to this point, it’s fine to use one from your experiences outside of medicine.  Considering the Duke model noted above (http://patientsafetyed.duhs.duke.edu/module_e/module_overview.html),  if applicable, think about how you might have classified it as skills-based, rules-based, or knowledge based..
  2. Identify one or more reactions you had to the resources as they pertain to mistakes in healthcare.

Please remember it is easiest to format this section using a bulleted list, as an example:

  • Shame – Mistakes on tests were not accepted in my house growing up. I remember multiple times when I came home with a “B” and had to tell my parents.  This was viewed as a mistake every time and caused me to feel great shame. Fear – When I heard Dr. X talk about her mistake on the labor deck, it made me worried that I am at risk for making the same error and there is little I think I can do to avoid it.
  • Camaraderie –  When Dr. Y talked about the response of his colleague to the mistake he made, it upset me to learn that his colleague did not support him.

Sources –  For your reaction to your own mistake, as noted above, set the stage for that experience and continue on to identify the source of your reaction at the time.  For your reactions to resources, also identify the sources. 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: create a realistic and specific plan that you can implement to mitigate the negative implications of one of your reactions between now and the small group session.


Panelists

  • Dr. Michelle Mentzer, a clinical psychologist from Indiana, who is the wife of retired USN chaplain, LCDR Bruce Mentzer. She has practiced and taught within the military community for many years.  She began her work at Marine Corps Camp Pendleton where she was a Group Manageron the mental health side at the Intervention and Treatment Branch in 2002, and she most recently taught for Johns Hopkins University in Baltimore while her husband was stationed at USUHS and Walter Reed (after retirement from the USN).
  • Dr. Rob Brutcher, LTC, USA, is an active duty clinical pharmacist from Walter Reed, and deputy director of pharmacy operations there.
  • 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 17 years.
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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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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IOMImproving Diagnosis in Healthcare - Patient Narratives Three narratives about diagnostic error and mistakes in healthcare...and how they might be avoided in the future.
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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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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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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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PropublicaWhat a New Doctor Learned About Medical Mistakes From Her Mom’s Death As a medical student, Elaine Goodman saw her mother’s safety compromised by multiple medical errors. As a physician, she tries to incorporate lessons learned into her own medical practice.
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Session originally created by: Adam Saperstein | SOM/GSN, Uniformed Services University | Director, Reflective Practice | Family Medicine