When doctors make mistakes

This story was first published in The Straits Times on Aug 31, 2013

Throughout our medical training and in the actual practice of medicine, it is expected that as medical practitioners, we should always do the best for our patients and their care must be our first and foremost professional concern.

In our interaction with patients, it is assumed that we will give our full and undivided attention to them and focus exclusively on their problems. Most times we do but at times, it can be difficult. Other irrelevant and unrelated thoughts intrude: that pile of unfinished and overdue medical reports sitting on one's table, an ailing parent, a child's impending school enrolment, and all that array of life's minutiae. And that can lead to bad consequences.

A real example

A few years ago in my outpatient clinic, I attended to a patient whom I have known for years and treated for schizophrenia. She had still the occasional auditory hallucination but was otherwise well enough to have meaningful relationships and hold a steady job.

It was a routine clinic visit: for me to check that everything was fine and for her to get her usual prescription filled. She was indeed fine, we chatted and with a couple of taps on the keyboard of my computer, I printed her prescription. As I handed her the prescription, my mind strayed to the next patient and a meeting later that afternoon. Fixing the date for her subsequent visit (I had been seeing her on a two-monthly basis), I realised that I would be away then on a trip abroad. I told her this and gave an appointment date in 10 weeks' time.

Nine weeks later and on the day of my return to work, I found out that she had been hospitalised. She had suffered a severe relapse after her medication ran out. Mortified and stricken with guilt, it dawned on me that I had omitted to make that change to her prescription. She told me later that she thought that a couple of weeks off medicine wouldn't make much difference.

In 1999, a report from the non-profit Institute of Medicine, which is the health arm of the National Academies in the United States, estimated that medical errors contributed to 44,000 to 98,000 preventable deaths each year in US hospitals. These were startling figures which were disputed in some quarters for the way that the study was done. However, a slew of subsequent studies were consistent in their findings of the common occurrence of medical errors and clear in their demonstration of the harm (physical and emotional) that followed in the wake of these errors. Among the most common mistakes are medication errors.

Preventing medical errors

In the successive years, herculean efforts have been made to lessen these medical errors. Extensive re-engineering of the complex medical system has been implemented - mostly based on the premise that medical errors are not made by bad people in health care but rather by good people working in bad systems. Policies have been implemented to encourage reporting of adverse events arising from care and taking a non-punitive systems approach.

Concepts and paradigms have been borrowed and adapted from industries like Motorola's Six Sigma, and Toyota's model of empowering workers on the shop floor to put the brakes on the assembly line to fix problems as soon as they are spotted. Information technology has been brought in, including computerised prescribing systems like the one I used to make out my prescription for my patient which, among other things, is meant to reduce dispensing errors by eliminating the illegible scrawl that doctors are infamous for.

But it is impossible to have, in the poet T.S. Eliot's words, "systems so perfect that no one needs to be good". In an essay in the New Yorker magazine, Atul Gawande, who is a surgeon in Boston's Brigham and Women's Hospital, wrote of his own medical mistake, and noted that while this retooling of the structure and processes of health care can make "dramatic improvements", there is still human fallibility to contend with.

He went on to write: "But there are distinct limitations to the industrial care, however necessary its emphasis on systems and structures. It would be deadly for us, the individual actors, to give up our belief in human perfectibility… This isn't just professional vanity. It's a necessary part of good medicine, even in superbly 'optimised' systems… No matter what measures are taken, doctors will falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it."

Owning up to a mistake

And so strive as we would, we would also falter and when that happens, we can't dodge personal responsibility and owning up to it. Admitting to a mistake can be very difficult for a doctor and the reasons are not noble: there is that personal sense of shame which incites a desire to hide or even cover up, there are the fears of a tarnished reputation, of angry recrimination from the injured patient and family, and of a possible medical liability lawsuit.

It is not unusual that health-care providers, hospital administrators and lawyers would worry that disclosure, apologies and even expressions of regrets are an invitation for litigation and can be used as discriminating evidence in malpractice suits.

The adversarial tort system may give some sort of justice to the patient and family but relatively few cases make it to the court. Research has also found that litigation does not reduce medical errors. Accounts of some of those who sued revealed that they did so not for financial reasons but because they felt frustrated, aggrieved and betrayed when the health-care providers stonewalled them. This despite the oft-repeated point that being candid and saying sorry may forestall some lawsuits or would at least lead to a quick settlement and lessen the toll on patients, families and doctors.

"Apologising," said Lucian Leape, the Harvard professor and former paediatric surgeon who is acknowledged as the father of the patient safety movement, "may be the most important thing we do after a serious event, both to help the patient begin to heal and to heal ourselves."

So one afternoon in a room in the hospital ward where my patient was recovering, I sat down with another senior colleague and a hospital administrator, and explained to the patient, her sister and elderly father how it had happened. (There was an extra layer of check by the dispensing pharmacist but somehow that failed too.)

I apologised for my mistake and acknowledged the distress caused to them. They listened quietly and without interruption to the end; the sister asked about the hospital bill - which of course was waived - and expressed her hope that it would not happen to other patients.

The title of the 1999 report by the Institute of Medicine was To Err Is Human; when I next saw this patient and her father in my clinic a week after her discharge from the hospital, they had already forgiven me. sg

The writer is Vice-Chairman of Medical Board (Research) with the Institute of Mental Health.

This story was first published in The Straits Times on Aug 31, 2013

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