Sunday, November 4, 2012

Celebrating Our Mistakes

This video is 19 minutes long but you should really take the time to watch it all.

Bill Chadwick who was a NHL referee before I was born, is alleged to have made an exchange with a doctor who sat close to the ice and like to heckle him.  Chadwick said something to the effect, "Yes doctor, I make a lot of mistakes; the difference is I don't bury mine".

I went to a Departmental retreat last Saturday.  The first one third of the retreat was on quality improvement.  Somebody said "we should celebrate our mistakes".   What a great concept, I would never have thought of that but I am still going to use it on my blog.

Years ago as a resident we had M+M rounds once a week.  Each staff at our local Centre of Excellence took the day in rotation and was supposed to present his cases.  If you were the resident who was involved in the event, you usually had to present the case.  You never liked to be the person who was presenting a mistake or a case that had not gone well but at the same time, it was a supportive environment.  Somebody usually said the same thing had happened to them.  And of all the teaching I got in residency, the M+M rounds were where I learned the most.

The CofE when I arrived there had a very active QI process.  Two nurses reviewed every single anaesthetic chart and reported variances to our four person QI committee.  This included trivial things like the blood pressure dropping on induction even if no harm came to the patient.  Typically one of the QI committee members would visit you in your room with a copy of the anaesthetic record and point out your errors.  If anything this exercise only taught me to fill in the valleys in my blood pressure.   We had another province-wide initiative.  If your patient died within 7 days of an anaesthetic you would get a summons to the Medical Records department to review the chart and fill out a form which was reviewed by a committee.  This was an interesting exercise because while sometimes you knew or suspected your patient was going to die, quite often patients died for no apparent reason.  At the same time the system was reactive not proactive.  It was punitive and not educational.

With the first reorganization of healthcare in the mid 1990s most of the QI activities ceased to exist.  The cost was cited but there was the suspicion that administration didn't want to know about what was going on because it might reflect on problems brought on by their policies and/or they might actually have to spend money fixing the problem.

The second blow to reporting and discussion of adverse events, was paranoia in the medical profession regarding the medico-legal implications of public confessions.  QI activities are supposed to be privileged which means that anybody who attends the meeting cannot be forced to testify on the case.  Changes to our provincial Evidence Act muddied the waters somewhat.  While we are reassured that QI discussions are privileged and cannot be subpoenaed, nobody wants to be the test case; our medical protective association has for years advised against participating in QI activities, if you think a legal action is imminent.  At the same time, administration while talking a great deal about quality and risk management, is in no hurry to support activities that might expose flaws in their agenda or force them to spend money to correct the flaws.

Our health region has a system called the Reporting and Learning System RLS, a computer based system whereby individuals can report adverse events and near misses.  I actually used it when this happened.   The problem with this system if that reports go into a black hole.  I am still awaiting a response to my report.

Making mistakes is of course the essence of how we learn in medicine and in life.  When I was a junior resident one of the staffmen liked to warn me over and over that one day I was going to make a serious mistake that would hurt somebody (I assumed he told every resident this and didn't think I was especially klutzy).  I got sick of hearing this and so one day I said to him, "How about I do it today so I can get it over with."  He didn't think this was funny.

When I was thinking about writing this blog, I was thinking about how I learned to ride a bicycle.  I didn't learn until I was 8 although I started trying much earlier.  I went through a lot abrasions both to my skin and my pride but one day I got on the bike and just start riding.  Maybe something clicked but more likely it was the sum of all the mistakes I had made trying to learn to ride a bike.  Parents in the 1960s were of course a lot more accepting of skinned knees and elbows.

Learning in medicine is the sum of experience, much of which is mistakes.  Some are obvious like blowing an IV or not being able to intubate; some have to be pointed out to you.  When you fail, you think of how you did it wrong and how you will try to do it right the next time.  When somebody criticizes you, you ask yourself, was that justified?  That is how we learn.  And it involves doing this on real live human beings.  Has anybody been to a simulation session that was even close to being realistic?

Of course many mistakes are only apparent to us and it is pretty easy to cover up or defend something especially if the atmosphere punitive not nurturing and supportive.  The problem is that when you don't confess your mistakes or when the system makes you defensive, you lose the learning opportunity the mistake gave you, as you replay the event over and over in your head what you did becomes more and more right.  Conversely by not being able to discuss freely your mistake, you may actually lose confidence in your abilities without the reassurance that your colleagues have had similar happening to them.  You also miss the opportunity of letting other people know of the pitfalls of doing what you did.

So if you are a non-physician reading this, you are thinking, all these mistakes in the name of training and experience;  is the system safe?  Well firstly, most mistakes are small mistakes.  There are of course single mistakes that can be catastrophic but the most serious adverse events are usually a cascade of small mistakes compounded by the failure to notice the small mistakes.  Small mistakes can be trivialized as is often the case when it is a system problem or minimized when it is an individual problem.  Failure to learn from mistakes, to take action so that the mistake doesn't happen again leads to serious adverse events.  So often the principle, no harm no foul exists in Medicine.

We are all human, we work on humans.  We are not perfect, our patients don't all present the same way.  That is the art of Medicine.  The doctor who realizes he is human, makes mistakes and learns from them is probably a pretty good doctor.  The most dangerous doctor is the one who thinks his shzt doesn't smell.

Sometimes however I just wish I could just say, "Doh".

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