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Where Are You When Things Go Wrong?

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kc_article_2008_whereareyou

Where Are You When Things Go Wrong?

By William Berry, MD, CRICO

Related to: Claims, Disclosure + Apology, Emergency Medicine, Primary Care, Insight into Risks of Ambulatory Care, Nursing, Obstetrics, Other Specialties, Surgery

Sometimes things in medicine go terribly wrong for a patient. Medicine is practiced by humans and, as an unfortunate consequence of our humanity, patients are hurt by our mistakes. Even the very best health care practitioners can make mistakes. 

Surgeons sometimes cut things that they shouldn’t cut; internists sometimes miss diagnoses; radiologists sometimes misinterpret X-rays; and nurses sometimes hang the wrong type of IV medication. Why is that?  It is because our eyes are not cameras, our ears are not tape recorders, and our brains are not computers.  Marvelous sensors of reality, they are flawed because the messages our eyes, ears, and brains take in have to be interpreted by a distractible, fallible intellect.  We know that the eyes used to perform intricate surgery and interpret complex diagnostic studies are the same eyes that “see” optical illusions and that are deceived by a quick hand in a magic show. Ears that hear the soft murmur in a baby’s heart are fooled by the ventriloquist. And our brains, more complex than the largest computers on earth, help us put it all together but are ever subject to error from fatigue and emotion. Unfortunately and in spite of our tremendous strengths we are vulnerable to seeing, hearing or thinking it “wrong.”

So what are we as physicians and nurses to do?  The first thing is to recognize our humanness and understand that some accidents are not preventable. The second is to acknowledge the need to fairly compensate patients who are injured as a result of that humanness. The third is to do everything we can to learn from our mistakes and build a system of care that is resilient enough to absorb, correct, and minimize these errors. And the fourth and final thing to do is much more difficult and challenging than the rest: to learn how to forgive ourselves for our imperfections. 

We now recognize formally that there is a victim besides the patient when there is a medical mistake. Doctors and nurses pay a tremendous price when they are responsible for what has gone wrong.  The nurse or physician who makes a mistake may leave clinical practice entirely, and/or suffer for a long period of time with guilt; both are tragic outcomes for everyone concerned, since time, skills, and talent get wasted, and committed healers walk away from a calling.

Perhaps the answer here is to better support each other when bad things happen.  The tendency is to think, “Well at least I didn’t make the mistake,” and to move on, instead of thinking, “That could have happened to me.”  Think about working at your own hospital or in your own practice to build a program to help and support each other and end the isolation. When things go wrong, none of us should be alone. 

 

Originally published December 1, 2008. Republished June 1, 2013. 


June 1, 2013
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