MISTAKES:
SELF-FORGIVENESS,
SELF-ADMONISHMENT AND MOVING FORWARD

How does a clinician’s "inner world" shift when faced with a mistake made? What is the emotional journey of recognizing, addressing and interrogating a medical error?

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Medical errors occur, and will continue to occur as long as human beings practice medicine. Rarely the result of genuine negligence, mistakes may stem from gaps in knowledge, insufficient clinical information, practice under time constraint, multitasking, or any one of countless personal factors (e.g., sleep deficit) (1). Morbidity and Mortality (M&M) conferences—"long-held legacy institution[s] in academic medicine"—investigate individual and system-related errors in an effort to improve future care (2). While not without educational merit, M&M’s traditional focus on "medical facts" (versus patient or clinician feelings) underscores a tendency to celebrate "ideals of infallibility" in modern medicine (3,4). This culture of perfectionism, although understandable considering physicians’ responsibility for human life, can create significant challenges for providers in the wake of mistakes or other self-perceived personal failings (5). Of course, medical errors first and foremost affect patients and families—but psychological and emotional impact on providers can also be significant (6). Errors beget “uncomfortable feelings of cognitive dissonance” as physicians struggle to reconcile their roles as healers, knowers and helpers with the human capacity to “[cause] harm to another" (7). Resulting emotions ("guilt, self-doubt, embarrassment, disappointment, self-blame, a sense of inadequacy, fear") and effects on work and personal daily functioning can be intense and long-lasting, with adverse outcomes ranging from isolation to depression and even suicide (4,5).


Complicating management of medical error is the need—both personal and professional—to apologize appropriately to patients and families.* Scholarship has established that provider apology can “decrease the risk of medical malpractice lawsuit[s]” and improve emotional outcomes for all parties involved (7). But fear—of judgement by colleagues, professional or legal repercussions—can impede apology (7). Whatever “confusion, inner turmoil [or] intrusive thoughts” clinicians experience in the aftermath of an error, therefore, may only be exacerbated by the complexities of formulating and delivering apologies in an intricate medical-legal system (4,8). Of course, organizations can provide practical guidelines for managing medical error. But no instructions can tell a provider how to feel.

*In contemporary medical literature, it is controversial whether near-misses, or even “minor medical errors that pose no harm,” require routine disclosure and apology by clinicians (8). Additionally, labeling of medical "error" can be subjective—especially when performed retrospectively as a referendum on medical judgements made emergently with little-to-no evidence-based guidance or clinical context available in the moment. We do not take a stance on these topics or unique scenarios here. Rather, we focus on more "black and white" mistakes with recognized potential to negatively impact patient care to some degree.

Illustrative scenarios:

  • A physician misdiagnoses a patient’s back pain, delaying treatment of a potentially curable cancer.

  • In an attempt to avoid excessive workup, a primary care physician does not order a certain lab test, which, if ordered, would have revealed a serious abnormality. The patient must now be admitted to the hospital.

  • A physician prescribes the wrong dose of a medication. Although the patient suffers some mild side effects, he recovers fully and is now stable taking a safe, proper dose.

 

References

  1. Diekema DS. Mistakes. UW Medicine Department of Bioethics and Humanities. https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/detail/70

  2. Pang S and Haider W. Humanizing the Morbidity and Mortality Conference. Academic Medicine. 2021;96(5):668-670.

  3. Wu A. Medical error: the second victim. BMJ. 2000;320.

  4. White AA and Gallagher TH. After the Apology: Coping and Recovery After Errors. AMA Journal of Ethics, Virtual Mentor. 2011;13(9):593-600.

  5. Nguyen AT. Empowering vulnerability: Overcoming the fear and shame of physician errors. Healthy Debate. December 1, 2020.

  6. Robertson JJ and Long B. Suffering in Silence: Medical Error and its Impact on Health Care Providers. J Emerg Med. 2018;54(4):402-409.

  7. Robbennolt JK. Apologies and Medical Error. Clin Orthop Relat Res. 2009;467(2):376–382.

  8. Guidelines for Critical Incident Stress Management. American Association of Nurse Anesthesiology. https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/professional-practice-manual/guidelines-for-critical-incident-stress-management.pdf?sfvrsn=ba0049b1_6