Kindlelife

Insight, Inspiration, Motivation

Making Mistakes


I had promised to write on this topic, a while ago, so here goes.

I was shocked to hear, in this day and age, that any medical educator can actually warn students to “never make a mistake!”

I can only hope that they did not mean it literally. I hope they meant to TRY to avoid mistakes. I hope they meant to say that in the business of human life and health, a mistake made by us can actually cost another human being their health, and therefore can be a very bad thing. I hope they meant that mistakes can be costly in many other ways as well. They can lead to litigation, immense stress, burnout, depression, and so on.

All of that would be right. But the fact remains that, despite everything we do, despite our best intentions, mistakes CAN happen.

What is most important to teach students and trainees is – How to avoid them, and how to deal with them, when they do happen.

Avoiding mistakes involves a lot of forward thinking, even play-acting in the initial stages, when setting up office. Work-flow has to be carefully analysed, and possible sources of error have to be eliminated.

For example, every lab report should be seen within a certain period of time, by the physician ordering it, and should only be filed away after it has been acted upon. In order to prevent mistakes in this sequence, it is necessary to make sure that every lab report is seen by the right physician, at the right time; there has to be some sort of code, that the physician puts on the report, that informs the staff of what action is required. there has to be a mechanism for the staff to see this, and then act on it, and follow up on those actions. Finally, the report has to be filed in the appropriate chart. A system has to be put in place, to ascertain that every one of these steps is carried out correctly, if mistakes are to be avoided.

Even after a system is set in place, and things are running smoothly, there have to be regular evaluations of these systems, to try and improve upon them, and make them more efficient.

When a mistake does occur, it can be a very scary thing. Mistakes can sometimes be small and inconsequential, and at other times bigger, and causing either distress or bodily harm of varying severity. It can also be the result of the action of any one person in the whole team of individuals involved in a patient’s care – and that includes clerical staff, as well as other support staff in hospitals. Often, however, the physician in charge has to take responsibility for it, anyway.

Whatever the cause of the mistake, early, full disclosure is always the best policy. It is of course, required by the law in Canada. There are plenty of resources, and workshops put out by the CMPA (Canadian Medical Protective Association), that help physicians understand what this means, and how to go about it. I am sure that such resources exist in other countries as well.

No matter what, the one thing that patients appreciate is a physician who tells them the truth. The majority of cases that go to court have been ones in which the patient felt that they were lied to, or not given answers to their questions in an honest and open manner. There will always be things we cannot explain when something goes wrong, however, and it is alright to say “I don’t know,” about such specifics. But overall, the patients and their families expect to see that the physician cares that something went wrong, and that they are not taking it lightly.

Perhaps the one thing that will be most appreciated when a mistake has been made, is an indication as to how this will be avoided in the future. If we can make it clear that we have identified ways to avoid it in the future, and put necessary mechanisms in place already, that will avoid a lot of conflict.

I do not know any physician who has worked for any length of time who can honestly say that they have not made mistakes. As far as I have seen, the person most affected, is always the physician, who feels guilty, and worries about making the same (or other) mistake again. They often find it hard to forgive themselves, especially when there has been a bad consequence. Over a period of time, however, they do learn to go on.

Ultimately, mistakes make us humble, they help us grow. They teach us forgiveness, and other valuable life lessons. When we do make mistakes, it is important that we try and learn everything there is, to learn from it, before we move on. And pray that we don’t make more!

Advertisements

April 22, 2013 Posted by | Personal Journey, Self Improvement | , , , | Leave a comment

   

%d bloggers like this: