Recently we found ourselves in the unenviable position of having to explain to a patient why we had explored his right testis for an impalpable lesion of the left testis. Fortunately the rather phlegmatic individual concerned was understanding, and accepted our explanation that the ultrasonography report had been inadvertently mislabelled, and that every step would be taken to avoid such errors in the future. This case, and the way in which it was handled, provides some useful lessons for all those who are involved daily in the risky business of making clinical decisions and undertaking surgical procedures, any of which have the potential to turn into medical disasters in a moment of error.
In medicine we seldom pause to dwell on the things that can go wrong . In this we differ from other ‘high-risk’ industries, e.g. aviation, where learning from accidents and near-misses is a long established practice, and a cornerstone of safety analysis and improvement. The case described above was a non-lethal ‘laterality error’. When the wrong kidney is removed, as happened last year in North Wales, the results may be much more serious and the media interest intense. The detrimental effect on the clinicians involved, the institution in which they work, and the patient and his or her relatives, can be immense.
So how should we respond when the inevitable medical accident occurs? The first step is to investigate the clinical incident; this has been described as a root-cause analysis . Most accidents are initiated by an ‘unsafe act’, in our case the mislabelling of the ultrasonograms. However, it is usually necessary to look further back into the ‘error-producing conditions’ that led to the unsafe act, and to the ‘latent failures’ or decisions made by management and others that may have had some bearing on the outcome. Information can be gathered from several sources, including case records, but the most useful details usually stem from interviews with those involved. Interviews should include the following key questions: ‘what happened?’ (this provides information on the key events and their chronology), ‘How did it happen?’ (which helps to identify any management problem), and ‘Why did it happen?’ (which helps to identify contributory factors). Of course, the incident should also be discussed with the patient and his/her family, and they should be informed of the results of the inquiry. If the media become involved a spokesman should be identified to liaise and to provide honest and accurate information, and the tendency for individual statements from others involved in ‘putting the record straight’ should be discouraged.
When obvious problems are identified after a single serious adverse event, action may be taken immediately. When more substantial changes are being considered, other data, including the results of other incident analyses, should also be taken into account. Recommendations should be included in a formal report and followed up with adequate monitoring of actions taken, with their outcome .
The effects of adverse incidents on patients and their families should not be underestimated. Medical injuries differ from other injuries in two important respects. First, patients are unintentionally harmed by people in whom they have placed considerable trust. Second, they are cared for by the same profession, in some cases the same clinicians, as those who were involved in the injury itself. When a patient dies as a result of a medical mistake, the trauma to his or her family may be very severe, especially if the death was potentially avoidable.
The trauma to patients harmed by treatment, and to their relatives, can be minimized if certain basic principles are considered. Clinicians should be honest and open about the incident, and what is being done to prevent its recurrence. The lack of an explanation, and an apology if appropriate, may be viewed by the patient with extreme negativity and may be a powerful stimulus to complaint or litigation.
The aftermath of a serious adverse event can also have profound consequences on the staff members involved, particularly if one particular staff member is seen, rightly or wrongly, as primarily responsible for the outcome. Those involved can experience shame, guilt and depression; litigation and complaints can impose an additional burden. The high personal standards of most clinicians may indeed make them particularly vulnerable to the consequences of mistakes. This tendency tends to be reinforced during medical training; the culture of medical school and training implies that mistakes are unacceptable and indicate in some way a failure of effort, character or personality .
When a major error occurs news of the incident spreads rapidly. Those involved can often feel isolated and vulnerable. As clinicians we should be more open about error and its inevitable occurrence. Senior staff members talking about their previous mistakes can be particularly effective. The need for support is not a sign of weakness. As doctors we are trained to be resilient, but almost all of us are grateful for the support of colleagues when a problem occurs.
Mistakes, often described by the military as ‘friendly fire’, are unfortunately a part of life. Facing up to errors and talking about them frankly in medicine can be effective in their prevention, but this is seldom practised. Managing their consequences efficiently can save heartache for both the patient and the doctor. In our case at St George’s, the repercussions for us, and for the patient, were fortunately minor. Next time we might not be so lucky! Learning the lessons of such events can reduce their recurrence and avoid litigation. There is much work to be done in this respect, but in the meantime urology and urologists could lead the way .