Medical mistakes: Just dont do it isnt a sustainable strategy

Good Studio/stock.adobe.com

“How to screw up and kill your patient, Method #4,372!”

These sarcastically cheery words from my classmate, scribbled in the margin of our notes, summed up the majority of my education on medical errors in veterinary school.

I spent four years learning all the things I shouldn't do if I wanted my patients to live-don't mess up the decimal, don't write abbreviations, don't mix up Drug A with Drug B.

I learned all about how to give bad news: “I'm afraid I have bad news that will be difficult for you to hear, Mrs. Smith.”

I never learned how to say, “Mrs. Smith, something horrible happened, and it was my fault.”

I thought if I took careful notes on all the ways that I could screw up, I would be protected from doing it. If I buried my clients in waivers and disclaimers, I could make them sign away my anxiety. If I monitored my technicians diligently and thoroughly, they would never make mistakes-and they certainly wouldn't complain to my superiors about my micromanaging personality and lack of faith in their abilities. (Spoiler alert: They totally did.)

I read the cautionary tales of negligence, oversight and shame sent to me monthly by my liability insurance company and said to myself, “That won't be me. That can't be me.” I put mental placeholders between me and the infamous "Dr. A." I would have double-checked the dosage. I would have recommended referral. I would have used an E-collar. I realize now this roundabout form of victim-shaming was only a subconscious way to try to protect my mind from the truth: One day this was going to happen to me.

Medical errors are exceedingly common, both in human and veterinary hospitals. Yet even though everyone makes mistakes, almost no one is talking about them. Not to each other, not to the public, sometimes not even to our closest friends or loved ones. Why?

Shame.

Defined by my personal hero Brené Brown as a fear of disconnection and unworthiness of belonging, the avoidance of shame is at the heart of every perfectionist. Be perfect, and everyone will love you. Slip up, and you will be exiled. And so, when we do inevitably make a mistake, we suffer in silence. We fear that we are alone in our failure and that there is something critically wrong with us.

We do what we have to in order to get through the moment. Then maybe we go home and cry or fall into a bottle of wine or a Netflix binge to numb the doubtful thoughts that whisper, We shouldn't be trusted with anything that anyone loves for the rest of our lives. Maybe we wake up the next morning and think about not going to work, that day or ever again. Maybe we go to work, but we have such high anxiety and fear that we can't function.

Maybe we leave the field.

Maybe we take our lives.

This happens too much, and for the health of our profession and everyone in it, it has to change.

It's well-documented that both patients and caregivers experience trauma, stress and grief related to medical errors. Administrative processes and protocols often focus on assigning (or denying) blame and punishing or removing those involved. There are rarely procedures put in place to address the systemic flaws that lead to errors or to help those who have committed the mistake, commonly referred to as “second victims.”

In fields where only the most exceptional get through the academic and professional rigors required to succeed, it only seems natural that the field becomes self-selecting for perfectionists. And sometimes a perfectionist runs up against the cold, hard truth that sometimes bad things will happen no matter what you do. Even more difficult? Sometimes bad things will happen because of what you do-that jarring reality is nearly unbearable. We are told from an early age that we must be good, not just do good. And so, when errors occur, our self-talk is not “I did something bad,” but rather “I am bad.”

Good Studio/stock.adobe.com

A 2009 study describes the healthcare provider as a “second victim” after adverse patient events.1 The study also shows that there are three themes that emerged in providers' long-term recovery from a medical error:

Thriving. We are able to put the event into context and realize that we are imperfect-but still good-doctors. We build our personal resiliency. We work to learn from the mistake and make our workplace safer.

Surviving. We “move on” in a literal sense, but only because we feel we have no choice. We repress our feelings and discussion about the event. At best, we can function with no visible adverse effects, but no added wisdom. At worst, we continue to be traumatized by the memory of the event. We overcompensate, double- and triple-check, micromanage our staff, and harbor a deep distrust in ourselves.

Dropping out. We can't live with the memory of our mistake or the fear and certainty that we will make another one. We feel paranoid, depressed and hopeless. Feeling unredeemable and untrustworthy, we may even contemplate self-harm. Dropping out may involve ceasing the performance of a certain procedure, changing fields or leaving the profession altogether.

So what helps? How do we process mistakes in a way that allows us to walk the path of long-term resilience instead of repeated trauma? To this, I'll add my personal thoughts, with the disclaimer that my only credentials are that I am a flawed, human veterinarian who walked away from a good job that I was really good at because I was too afraid to make another mistake.

> Remember that your merit is not binary. One mistake in a career of lives saved and bettered does not make you a bad doctor.

> Understand resiliency is an action, not an attribute. You are not “born brave.” Small, everyday acts of courage build your strength, one molecule at a time.

> Create a personal narrative that embraces a growth-based mindset. You are a work in progress-always. So is everyone else.

> Don't strive for perfection. Understand that letting go of the need to be perfect does not equate to lowering your standards.

> Create good habits for positive self-talk. Surround yourself with people who will hold you to it.

> Break up with superstition. It perpetuates the idea that your actions can prevent bad things from happening to you, and if bad things do happen, you've done something wrong.

> Explore your “bone pile.” Take a look at those cases and mistakes that haunt you-but don't live in it. Understand the events are in the past, but what you can learn from them can stretch far into the future.

> Remember that every fail safe was born out of failure. From calculators to childproof lids to traffic lights-these things exist because someone lived out their worst nightmare and decided to make the world a safer place because of it.

And finally, when it comes to processing our own failures, understand that it's not just about learning to move on, but about learning that we are fallible-that effort, merit, failure and worthiness can all exist simultaneously in the same beautifully flawed, complex human being. 

One thing I tell my daughters when they experience fear and anxiety about the unknown is to find someone who looks more scared than you. Help that person feel at ease. Help them feel less alone. More than likely, the things you tell them are what you need to hear yourself. 

As someone who has marinated in my perfectionism until my toes got wrinkly, this tactic has helped me have a healthier outlook on mistakes. I share my bone pile with my colleagues. I tell them about the things that scare me. I tell them about the near misses. I tell them about the patients that still twist up my insides at 3 in the morning. 

The best part? Instead of responding with silence, judgment or shame, more often than not I find they reach back out to me and open themselves up in return. Even more amazingly, they will often then share their own suggestions for getting through those cases, or talking to those clients, or moving on from those heartaches. And in that moment, the world feels a little smaller, a little safer and a little kinder. It's the kind of world that a profession full of perfectionists and self-critics deserve to spend a little more time in. 

References:

1. Scott SD, Hirschinger LE, Cox KR, et al. The natural history of recovery for the healthcare provider “second victim” after adverse patient events.” Qual Saf Health Care 2009;18(5):325-330.

Dr. Meghann Berglund is a proud Colorado State University Ram and the owner of Red Dog Veterinary Relief Services in Colorado. Her hobbies include camping, labeling things and catastrophizing. She is the co-founder of Collective Geekery, the handcrafted art business that steals her free time but returns her inner peace.