Failures – Why doctors don’t learn from them
One morning in 1990, as a registrar in Obstetrics and Gynaecology at the Kuala Lumpur General Hospital, I was presenting at a pass over round, when the Head of Department picked up on a mistake I had made the day before, when I was on call. I acknowledged the mistake. I apologised and informed him that I would make sure it would not happen again. The Consultant was taken aback. He told me that it was the first time he had encountered someone who owned up to his mistake. He said, junior doctors normally gave all kinds of excuses when a mistake occurred. He confided that he did not know how to react, except to tell me that he accepted my apology. He then reiterated not to repeat the mistake.
Fast-forward 32 years; I recently, made a mistake. Although I treated the patient with good intentions, there was an unforeseen complication. When I reviewed the case, I realised that I could have avoided it. I felt ashamed of myself. I could not think clearly and perform the same procedure again for many days. I informed her of the error and told her that I will fix it. Fortunately she recovered from the complication without much difficulty.
I wanted to tell someone about this mistake. I wanted it to be recorded somewhere so that others can learn from it but I was fearful. I wondered what others would think of me. I was worried about my reputation and worse of all, I was worried that the patient will sue me. So I wrote down my feelings and kept quiet, hoping that one-day I will have the courage to present this mistake to my peers.
The Airline Industry
Let’s compare this with the airline industry. Its safety record is immaculate. In the book “Blackbox thinking” Mathew Syed wrote that “In 1912 , eight out of fourteen US Army pilots died in crashes: more than half. Today, however things are very different. In 2013, there were 36.4 million commercial flights worldwide carrying more than 3 billion passengers. Only 210 people died. For every one million flights on western build jets, there were 0.41 accidents – a rate of one accident per 2.4 million flights. In 2014, the number of fatalities increased to 641, in part because of the disappearance of Malaysian Airlines Flight 370, where 239 people went missing. Most investigators believe that this was not a conventional accident but an act of deliberate sabotage”.
How did the airline industry make such improvements? It all boils down to the attitude of the industry. “Every aircraft is equipped with two, almost- indestructible black boxes. One of which records instruction sent to the onboard electronic systems, which records the conversations and sounds in the cockpit. If there is an accident, the boxes are opened, the data is analysed, and the reason for the accident excavated. This ensures that procedures can be changed so that the same error never happens again”.
Another important culture in the airline industry is the culture of reporting near misses. The near miss reporting system is a standardised tool developed by the International Air Transport Association (IATA), which airlines use to record and report safety – critical occurrences that do not result in injury or damage. The reporting helps airlines identify areas where corrective action may be required, and also provides valuable training opportunities for staff. This can be particularly useful when dealing with complex or unusual situations.
Pilots who report a near miss must report in writing what happened, why it happened and how it was avoided. As part of the reporting process, pilots will describe the situation, the event itself and explain why they think it was a dangerous or risky thing to do. All reports are confidential until an investigation has been completed. Pilots who don’t report near misses risk losing their licences.
Health care Industry
Now, lets look at the health industry. Mathew Syed wrote “ In 1999 the American Institute of Medicine published a landmark investigation called “ To Err Is human”. It reported that between 44,000 and 98,000 Americans die each year as a result of preventable medical errors”. He also wrote that in 2014 in testifying to a senate hearing, Peter K Pronovost, Professor at the John Hopkins University School of Medicine, said that it was equivalent of two jumbo jets falling out of the sky every 24 hours. He said that preventable medical error in hospitals, is the third biggest killer in the United States behind only heart disease and cancer”.
Why is this so? “One reason Mathew Syed wrote is that there is no open reporting system in the health care industry. With open reporting and honest evaluation, these errors could be spotted and reforms put in place to stop them from happening again as it happens in aviation. One explanation is that in the airline industry if there is a mistake the pilot will perish whereas in the medical field, a mistake may cause the death of a patient but not the doctor. So doctors are not as motivated to learn from their mistakes compared to pilots. Failure to learn from mistakes has been one of the single greatest obstacles to human progress”.
Documenting mistakes
How nice if we could have a system where mistakes are recorded anonymously and discussed among colleagues so that others can learn from it? One such attempt is the maternal mortality review started in many countries. When a mother dies, the Ministry of Health does an investigation anonymously and a report is made so that all doctors can learn from this mishap. Unfortunately the Malaysian Ministry of Health’s confidential enquires is published 3-5 years later and the benefit of learning quickly from a mistake is lost her although the intention is good. This system was tried with morbidity but that does not seem to have succeeded.
Current state in Private Practice in Malaysia
In the private practice in Malaysia, most specialists are solo practitioners. They work by themselves and are solely accountable for their actions. The hospital where they work has a management team, comprises of non doctors. The Medical Director helps the management with medical matters concerning doctors. However the onus is for each discipline to self regulate themselves. How can this happen? Each consultant in a speciality is a competitor of the other. Sometimes, there is bad mouthing of one another, to gain patients. It is impossible for a group of doctors in the same speciality to sit down and discuss their mistakes. They will feel that their colleagues will look down on them. So this will never happen in the current private health system in this country. This is more so if we cross speciality. The only discussion that is regular and warranted by the Private Health care act is the Mortality meeting whereby all mortality in the hospital is discussed among doctors and a report is written and sent to the ministry. Even then, the colleagues are kind to the presenting doctor, and do not question him on any mistakes that occurred.
Any solutions?
How can we overcome these difficulties? One way is for specialities or even the Ministry of Health to start a database on mistakes that occur. All doctors are encouraged to submit whatever mistakes that occur, to this database anonymously. These mistakes are then discussed and the lessons learnt will be disseminated to the all the interested medical personnel. There will be some difficulty maintaining anonymity because any leak may lead to a medicolegal backlash. Currently the law even allows lawyers to gain access to mortality meeting minutes and that is discouraging. I presume laws can be enacted to protect doctors who are reporting their mistakes. However this will require great initiative and motivation by politicians.
The simpler method is for every doctor to write down his or her mistakes. They can discuss their mistakes with their friends and analyse them. This analysis can be documented and filed away. It can be presented some months or years later when the possibility of medico-legal risk is very low. Presenting these mistakes to colleagues will be a learning experience for everyone.
How I do it?
This is what I have been doing over the years. When I give a talk on a topic, I include mistakes that I have made in a particular area so that younger colleagues will learn from my mistakes. This will not change the medical industry as drastically as in the airline industry but at least I would have contributed my part in educating others on the mistakes I have made during my working life.
What advise can I give young doctors?
- Keep a journal. Write down what you do everyday, especially the mistakes that you have done. Talk to your trusted colleagues and analyse the mistake.
- I recently I started a video log (vlog) whereby I record myself talking about the mistake I have made, how I felt about it and how I could have avoided it. We have the tendency to push back uncomfortable memories into the deepest recesses of our brain and by recording it we can relive our experience and therefore, learn from it, improving our overall skills.
- Remember to allocate some time in the future to read what you have written and watch the recordings as well. You will be surprised at how you sounded before and what you have learnt from it.
- Make attempts to disseminate what you have learnt from the mistakes you have made to other colleagues. This may be uncomfortable for you.
- If you work in an environment where you can work well with your colleagues, try to form a discussion group where you can meet and discuss your mistakes. I find this difficult in the current environment in private hospitals where management has a policy of divide and rule.
Selva
1/1/2023
I would like to thank:
My wife Sarojini Palany for editing this manuscript
Dr. Gunasegaran for reading through this blog post and giving good suggestions.
