Monday, May 30, 2016

Doctor do you ever make mistakes?

A few weeks ago a patient asked me an intelligent question.

He was in the OR, the checklist had been done, IV started, monitors on and he had even had a sniff of midazolam.  That was when he looked up and asked me, "tell me doctor, do you ever make mistakes?" The circulating nurse was at the head of the bed and heard this, so I had to answer.  Here's what I said, "yes I make mistakes but I try to detect them early and fix them right away."  And then I gave the rest of my induction cocktail.   After he was asleep, I said to the nurse, "any doctor who thinks he doesn't make mistakes is dangerous?"

This made me think about the nature of mistakes.  During my time as site chief I was of course involved in QA or QI and dealt with a lot of mistakes but never really got a handle on the best way to deal with them.   We read all the time about patients dying as a result of medical errors.  So let's look at mistakes.

Giving the wrong drug is an obvious mistake.  This can be like giving adrenaline instead of atropine, or phenylephrine instead of oxytocin; two mistakes I have heard of.  This is unfortunately too easy with lookalike drugs and the tendency to change suppliers on a weekly basis.  A few years ago I was having dinner with a bunch of other site chiefs and we started talking about the drugs we had heard of injected intrathecally by mistake.  These included ondansatron  (the only thing that happened was a failed spinal) and tranexaminic acid which should have caused a problem but didn't fortunately.  These are situations where you inject something other than what you thought you injected.

There are also times when you inject a drug which turns out to be a mistake.   Obviously these would include giving a drug to which the patient is allergic to, giving Pentothal to someone with porphyria or succinylcholine to somebody with MH.  Giving way too much of a drug to a little old lady could also be considered an error, one I think we have all committed.  

There are errors of judgement.  Giving a muscle relaxant to a difficult airway is one such case.  This is often a judgement case; the previous neck dissection is pretty obvious, the person with a small chin not so much.  Some errors of judgement are immediately obvious.  Others only become obvious on reflection either by yourself or frequently by somebody else who is reviewing the case.   Sometimes things look a lot more obvious in retrospect.  

There are of course errors of omission.  Missing something in the patient's history.  Not making sure you have the right equipment or not noticing the blood pressure dropping to mention a few.

There are of course times when you do something because you think it is the right thing to do and it isn't.  Take giving metoprolol for high risk surgery, or tight glucose control.  Remember flecainide and tocainide?  (Actually those were over 25 years ago most people don't).  One of my staff when I was an intern insisted on running IV lidocaine on our MI patients; the worst tongue lashing of my career came when I failed to restart the lidocaine after somebody stopped it.  Turns out IV lidocaine actually increases mortality.  Still waiting for the apology.  Then there is homonal therapy.  There are lots of treatments which we are still using that are going to be shown to make the patient worse.  My money is on proton pump inhibitors as the next culprit.

There are also complications of medical care that may or may not be due to mistakes.  We accept wound infections as a consequence of surgery but we know that some surgeons have higher infection rates or other complications.  

We often now talk about system errors as cause of adverse events in the OR but we have to accept that sometimes the adverse event is entirely due to human error and no system would have prevented what happened.  Looking at the individual, we have to then assess whether this was just a bad day or is this part of a pattern of multiple errors.  Sometimes we respond to what was an individual error by initiating cumbersome systems that will not prevent or mitigate the error.  

Some mistakes have immediate and serious consequences.  Some mistakes make cause consequences if they become part of a sequence of other errors or events.  Some (most) mistakes have no consequences at all.  For example if you forget to make sure you have a suction, that is only a problem if the patient vomits at the beginning or end of the case.  When to tell a patient of a mistake where there are not consequences or even when there are is tricky.  A few years ago at another hospital a staff anaesthesiologist was working with a medical student who after starting the IV hooked up the sux drip (remember those) instead of the IV.  The staff noticed this right away, but not before the patient became apneic.  The patient was put to sleep right away.  The staff however felt that he had to explain what had happened, to the patient who had no recollection of the event.  The result was that the patient sued him, claiming among other things sexual dysfunction, apparently a little known consequence of awake paralysis.   When deciding whether to disclose your mistake, you will get conflicting advice.  If you contact your malpractice carrier, in Canada the CMPA, you will be advised to talk to nobody about the case.  On the other hand hospitals have disclosure policies and our hospital has "disclosure coaches" who can help you to disclose the event to the patient.  This is probably less benevolent than it is about shielding the hospital from liability.  Then there is the question of how serious do the consequences to the patient have to be before you disclose.  Certainly if you are seen as covering up the mistake, things are not going to go well for you.

When I was a resident we had weekly M+M rounds which were public at which we presented our mistakes or how we got out of situations caused by other people's mistakes.  It was accepted that the discussion was privileged and could not be used in court.  These were the most educational rounds of my residency, especially as frequently a resident in the audience was put on the spot which forced you to come prepared and think.  Now we don't have M+M rounds or have them infrequently because people are scared that they are no longer privileged and could be used in legal proceedings.  Our legal department has not been able to give us a straight answer on this.  A year or so ago we had an obstetrical disaster with a good outcome.  Our OB department agreed to discuss the condition in joint rounds as long as we did not present the case.  When I was site chief, I would hear about something that had happened in the OR and would approach the individual(s) involved to get something in writing which they often refused even though as our department's rep on the surgical QI committee,the information was clearly privileged.  Our "quality" department was less than helpful here.  

But what about mistakes.  A few simple rules.

1.  Try to recognize them early on.  This means constantly questioning what you do.  No matter how good you are, you are going to make mistakes and some of them may unfortunately be catastrophic. 
2.  Fix them right away if you can. This is as opposed to covering them up.
3.  Own up to them.  That can mean disclosing them as above or just accepting that you made a mistake.  When I re-started adult band, my conductor told us that there was a convention that if you played a wrong note, you should admit it.  You can save a lot of rehearsal time by just saying, "I played an F# instead of F".  If you own up to a mistake, you might find that others have made the same mistake and you might all learn from them as below or at least others may be more vigilant about making the same mistake.  At the same time don't beat yourself up about them.  Move on.
4.  Learn from them.  You are still going to make the same mistake twice or even three times but you should learn something and even change your practice a bit.  On the other hand don't make ridiculous practice changes as the result of a small mistake or uncommon situation.  Where I first worked we had an OB who did not use cautery because when he was a resident, a single patient got a burn.  Stat sections with him were an interesting experience.
5.  Support your colleagues who make mistakes (this excludes surgeons and internists who you should always try to nail).

Sunday, May 22, 2016

Oh by the way it's called Medically Assistance in Dying Now.

Afterall why use one good word (euthanasia) when you can use 4 words especially when you get a pretty good acronym out of it (MAID).