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Making Mistakes In Practice

Developing a consensus statement

Emma M Kennedy, BMBS, FRACGP, is Medical Educator, Royal Australian College of General Practitioners Training Program, Lecturer, General Practice Northern Territory Clinical School, Flinders University and a general practitioner, Bagot Community Clinic, Darwin Northern Territory.

Sam R Heard, MBBS, FRACGP, is Regional Director, Royal Australian College of General Practitioners Training Program, Director, General Practice Education and Research Unit, Northern Territory Clinical School, Flinders University and general practitioner, Malak Square Medical Centre, Malak, Northern Territory.

Objective To develop a reference statement for the appropriate management of mistakes in the general practice training environment.

Method The setting was a series of focus groups held during workshops with The Royal Australian College of General Practitioners Training Program in the Northern Territory (NT). The participants included NT supervisors and registrars, and representatives of the Consumer Reference Group, Top End Division of General Practice.

Results A reference statement and mutually agreed list of duties for registrars, their supervisors and patients.

Conclusion Mistakes are a part of the practice of medicine and can impact on everyone. An appropriate response and the opportunity to reflect and learn from the experience are important elements in minimising the adverse impact. We recommend that the issue of mistakes be considered a priority in the teaching of medicine.

Received 26 June 2000; accepted after revision 7 November 2000

Mistakes are part of the practice of medicine in hospital¹ and general practice.² We all make mistakes by act or omission during our working lives. These mistakes may have a significant impact on our roles as doctors,³ our wellbeing and even on our community. Causes of error are multifactorial and include errors of systems, communication and human factors.^4-5 Mistakes are inevitably more common during learning and registrars are likely to be more vulnerable to an adverse emotional reaction. This is particularly true in rural training settings such as the Northern Territory where registrars take on more responsibility earlier in their career. Dealing with mistakes appropriately may be difficult, overshadowed as it often is by discussion of prevention of mistakes and their medicolegal impact. It is a neglected area in medical education.

Definitions of a mistake in medical practice vary. 'Several factors, such as the severity of the outcome and the perceptions of colleagues and others - including the patient and family - may cause an event to be considered as a mistake.'⁶ For the purposes of this paper we have used the following adaptation of a definition by Baylis.⁷

A mistake is an erroneous act or omission resulting in a less than optimal or potentially adverse outcome for the patient.

We respond to mistakes with a variety of coping strategies. Some effective strategies include acceptance of responsibility, focusing on problem solving and managing our emotional response.⁶ Mizrahi⁸ describes a range of negative coping mechanisms employed by doctors in training when a mistake is made.

• First, 'denial' - which involves redefining errors as nonerrors and may even involve negation of the concept of error.
• Second, 'discounting' - when personal responsibility is minimised and blame externalised.
• Finally, 'distancing' - when we manage our guilt by removing ourselves from the patient's care.

These mechanisms are often unsuccessful, a finding confirmed by Baylis⁷ when critically examining the reasons physicians gave for not admitting or partially admitting their mistakes.

Mizrahi raises the need to recognise the training doctor's vulnerability and their acculturation to the role of doctor; both factors affect their perspective on mistakes. Robinson⁹ comments on the change she noted in medical students' behaviour when she was working as a patient advocate in the 1970s. She found medical students to be idealistic and open during their first years, becoming guarded and defensive later and 'already constructing their professional protective carapace.' The culture of medicine is a barrier to openness and honesty, particularly when we are vulnerable. We have an ethical duty to be honest and patients have a right to know the truth.¹⁰ Furthermore, unresolved guilt may impact negatively upon our response to similar encounters in the future.

Couper¹¹ and Hilficker¹² share their personal experience of mistakes, highlighting their acute need for reassurance of their own medical competence and expressed fear of their colleagues' impressions and patients' reactions. They emphasise the importance of more open and honest discussion within the medical profession to improve awareness and mutual support when mistakes are made. Newman¹³ in a study of interviews of family physicians' experiences of mistakes has proposed that doctors will benefit from sharing experiences, leading to an increasing acceptance that mistakes are a normal part of practising medicine. This sharing can occur in critical incident review, general practice surgery meeting or during more formal audits of outcome of health care.¹⁴

Following a visit by Ian Couper to our unit we were motivated to develop a consistent response to aid registrars and supervisors when mistakes occur. We aimed to produce a consensus statement with practical guidelines for general practice supervisors and registrars participating in training in the Northern Territory.

Methods

Two separate meetings were held as part of a GP supervisors' workshop and a GP registrars' workshop over two months in 1998. The first group consisted of 17 GP supervisors from the RACGP Training Program and the second included a group of 15 registrars and a group of six patient representatives from the Consumer Reference Committee of the Division of General Practice. Each group was introduced to the topic with a review of the literature. Participants then split into pairs and were invited to share their experience of making mistakes. Some of the scenarios raised were then discussed by the whole group. Each group subsequently split into smaller groups to develop a consensus statement on making mistakes in practice. The discussions were noted by three medical educators at each meeting. A list of the duties of supervisors, registrars and patients arose from these discussions. At the registrar workshop the consumer group and the registrar group met to discuss their statements together. The three statements were then 'merged' and returned to the participants individually for comments and changes. Minor changes were made on the basis of these responses. This method allowed the topic of mistakes to be raised in a relevant way providing opportunity for reflection amongst peers.

Results

Discussions were thoughtful and at times passionate. All participants had experience of making mistakes, some with serious consequences. The following example, offered by a registrar, illustrates a mistake with potentially important consequences.

A woman attended a general practice for an antenatal check. She had noted the presence of vulval warts that she had had previously. She inquired as to whether it was all right to use the podophyllin she had at home to treat these. The registrar had not used podophyllin and looked up the contraindications in MIMS. She read from the wrong part of the text by mistake and told the patient that it was OK.

There were no consequences from this mistake as the patient read from the prescribing information in the box at home and found pregnancy listed as a contraindication. She rang the doctor and informed her. Another mistake offered by a supervisor is described below.

An elderly lady admitted to the local hospital was on a variety of medication for her congestive cardiac failure and hypertension, including frusemide and digoxin. She was dehydrated and delirious and the doctor performed basic investigations including electrolytes and commenced fluid replacement. In the course of the busy afternoon and evening he forgot to check the results of the tests and the patient's hypokalaemia was only discovered when she remained delirious and developed muscular spasm. The doctor was shocked at how easy this life threatening mistake occurred and felt an insecurity about how this would appear to his colleagues. She recovered with potassium replacement but the doctor suffered doubt and anxiety about his competence.

A number of themes emerged in the discussions and are illustrated by comments made by the participants in Table 1. The emotional impact of making mistakes was the most prominent feature raised in discussions. Registrars, in particular, expressed fear of the reaction of others and the need for support. There was general acceptance that this was an important area of practice; no one had discussed making mistakes previously in an educational setting.

Table 1. Comments by participants organised by theme
Feelings	'If you have a good relationship with a patient, get to know them a bit, they are a bit more forgiving.' (registrar)
	'If you don't deal with it (anger) you end up taking it out on people around you. For example, the next patient ... it doesn't go away.' (supervisor)
	'Acknowledge anger.' (supervisor)
	'It is like a grieving process.' (supervisor)
Fear	'Colleagues might be derogatory. They don't want to lose face. It can be a boost to their egos ... thinking 'I'm not that bad!' (registrar)
	'It is very hard to undo things in medicine ... it can be a scar for life.' (registrar)
Medical 'culture'	'Not admitting mistakes is part of the culture of medicine.' (registrar)
	'Pride, with high expectations of self and of the profession, doesn't allow for mistakes ... the 'never fail' attitude is quite unrealistic.' (registrar)
Support	'It doesn't help (resolution) when peers say: 'It could happen to anyone.' They're dismissive. Colleagues hinder saying: 'There, there, that's OK; but they don't really believe it.' (registrar)
	'Lack of support from a senior partner is a hindrance to dealing with the mistake.' (supervisor)
Learning	'It's important that in our undergraduate education the specialist culture never acknowledged making a mistake. Maybe part of teaching should include acknowledging mistakes to allow others to expect it's OK to discuss mistakes.' (supervisor)
	'It helps [to talk to a colleague] if it leads to learning. It can leave a positive effect. You need a colleague to take this approach.' (registrar)
	'This is the first time I've talked about this' (registrar)
	'Reading in journals about other people's mistakes helps you feel less guilty when recognising others do the same or worse things.' (supervisor)
	'Educate registrars to be comfortable with vulnerability.' (supervisor)

Emerging from the groups was a set of duties for supervisor, registrar and patient that are combined in Table 2. Informing the patient was considered the most onerous of these and was felt to be the duty of the doctor who made the mistake. If this was the registrar it was felt that this should be done after discussion with their supervisor, in most situations.

Table 2. Duties in a learning environment
Supervisor	Registrar	Patient
• be accessible (on cue!) • recognise that mistakes are an inevitable part of learning • be nonjudgmental • be constructive and supportive • help to institute damage control • offer second opinion • be confidential • have appropriate medical defense cover; check registrars' also • provide regular opportunity for debriefing • be concerned for a registrar who won't recognise a mistake • if discovering a mistake, to tell the person who made the mistake before anyone else • discuss own mistakes • attend CME and peer review meetings	• have realistic expectations of learning in general practice • tell the supervisor of the mistake as soon as it occurs • tell the patient of the mistake after discussion with the supervisor • have appropriate medical defense cover • attend CME and peer review meetings • learn from mistakes	• have realistic expectations • be involved in minimising harm

Reference statement The following consensus statement was agreed to by the participants with the aim of minimising the harm to patients and doctors (and the doctor-patient relationship).

A reference statement on making mistakes in practice

We acknowledge that we make mistakes when practising medicine and at the time we will have strong feelings - anxiety and concern, fear or even panic! We can be tempted to keep it to ourselves but there is some evidence that this may be harmful. Perhaps the most helpful thing to do at that moment is to share our story with a colleague whom we trust - this might make it a lot easier to talk to the patient who will certainly want to know. There may well be things that can be done to prevent harm. There will often be an opportunity to learn from this experience and reflect on the impact on our patients and ourselves.

Discussion

The consequences of mistakes impact upon our patients, our peers and ourselves, both intellectually and emotionally and are summarised in Table 3. We experience anger, guilt and disbelief, and we feel 'bad'. Our confidence in our own competence can be shattered³ and we will almost certainly feel embarrassed. We may experience a 'grief response'¹⁵ at the loss of our self image as a 'competent doctor'. The significance of the response may not reflect the seriousness of the mistake. All doctors need support, to reflect on, and incorporate this aspect of practice into their lives.¹⁰ Unresolved emotions may impact in indiscernible ways on our future relationships with peers and patients. Regardless of fault it is important that we learn from the experience, recognise the opportunities without diminishing the perceived importance to the patient and others. Clearly, discussing mistakes openly is an important task for teachers also, in order to be appropriate role models.¹⁶

Table 3. Consequences and opportunities of mistakes in practice
	Cognitive	Emotional
Consequence of making a mistake	Harm Effect on medical judgment Financial impact Litigation	Shame Doubt Fear Guilt Sadness Loss Frustration Panic Self care Trust and forgiveness Empathy for others Humility
Opportunity from the mistake	Acknowledgment of reality Reflection Learning opportunity Harm minimisation Explosion of myth - 'medical culture' Promotion of awareness of issues among colleagues Education - medical students - registrars - colleagues - patients Mutual support

The groups felt that honesty with our patients and our peers is crucial for effective resolution of the consequences of the mistake. Without education about making mistakes, the 'culture' in which we practise determines how we respond.5

The importance of prevention of mistakes by improving equipment, communication channels, and documentation should not be understated. However, recognising and dealing with mistakes in a supportive environment is an essential precursor to dealing with mistakes systematically and holistically. Having shared our fears and feelings with a trusted colleague, we are better able to discuss issues in a larger group.

A clear understanding of the issues arising from mistakes in medicine is a priority for medical education.6,10 The duties of supervisors must be clear and undertaken reliably. Our duties list was generated with the aim of preventing (further) harm and improving the standard of practice while dealing with the emotional response of the doctor and the patient. It could be used as a teaching aid or when introducing a new doctor to the practice. It has been useful when discussing mistakes in education sessions, with junior doctors. We recommend that all medical units have a protocol for dealing with mistakes that meets the needs of patients, learners and supervisors. We run the risk of failing to recognise the emotional impact of mistakes if we only attempt to address the issue from a managerial perspective or a solely preventive approach.

Acknowledgments

We would like to thank the supervisors and registrars of The Royal Australian College of General Practitioners Training Program of the Northern Territory and the representatives of the Top End Division of General Practice Consumer Reference Group, who contributed their thoughts and experiences to the development of this paper. Their enthusiasm and commitment to learning and teaching continue to encourage and inspire us. We would also like to thank Dr Ian Couper whose reflections encouraged us, and Dr Kayte Evans for assistance and support.

References

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Implications of this study for the GP

• Mistakes are common. They have major consequences for doctors and patients, some of which can be ameliorated and even turned into opportunities for learning.
• A number of approaches have been proposed by previous authors.
• A consensus between registrars, supervisors and patients on how mistakes should be handled in general practice training is outlined.
• A summary of 'duties' for each party is outlined.

Last Modified: 8 August 2001