Improving Patient Safety: The Role of Learning from Medical Errors

In everyday and strenuous work, medical errors occur equally in everyone: learners, novice specialists and experienced doctors.

The emotional consequences of this are diverse:

• Increased anxiety about future mistakes
• Loss of self-confidence
• Difficulty sleeping
• Decreased job satisfaction.

It is possible to develop depression and emotional burnout if you stay in such states for a long time.

Of course, the problem of mistakes by medical workers is very acute and has been discussed for more than one century, and so far, the best minds of both past and present centuries have not been able to come to a consensus: does a doctor have the right to make a mistake, and is there a penalty for this?

Medicine is the most complex form of human activity, requiring, in addition to special knowledge and practical skills, intuition and high spiritual qualities. The phrase refers to the ancient Roman philosopher Cicero:

"To err is human nature".

It's important for doctors to acknowledge and take responsibility for their mistakes, and to use them as opportunities for growth and improvement.

We will examine the types of reactions and methods of responding that can reduce anxiety, adapt, and avoid self-destruction when a mistake has already been made.

World Health Organization on Medical Errors

According to the World Health Organization (WHO), medical errors are a major public health issue and a leading cause of death and injury worldwide. Here are some statistics.

These statistics highlight the need for healthcare organizations to take steps to prevent medical errors and improve primary care. The WHO has developed a number of initiatives aimed at reducing the incidence of medical errors, including the Global Patient Safety Challenge on Medication Safety, the Global Patient Safety Challenge on Health Care-Associated Infections, and the Surgical Safety Checklist.

We have asked our clients about the mistakes they are most afraid of making. You can see the results in the table below.

Destructive Ways of Reacting to Near Misses and Errors in Medicine

Researchers who have studied the behavior of novice doctors and medical students have identified three possible destructive approaches to mistakes:

1. Denial
2. Justification
3. Suspension.

Denial

When we interviewed doctors about the mistakes made by their colleagues and themselves, almost all recognized the mistakes of their colleagues, while more than half recognized their own.

Nonetheless, most respondents denied the possibility of their warning, attributing bad outcomes instead of human error to undesirable outcomes. Theу explain adverse outcomes by the convenient phrase "this is our job".

The denial is so strong that some healthcare teams are unable to remember mistakes.

The stronger the denial, the more difficult it is to analyze the causes of your own failures and learn from your own experience.

Justification

Justification means shifting responsibility for your actions to others. Specialists using this approach tend to blame the healthcare system, managers, and patients for the mistakes made more often than others.

When a medical error occurs, it can be tempting for healthcare professionals to try to justify their actions or blame someone else for the mistake. However, this can create a culture of defensiveness and make it more difficult to identify the root cause of the error and prevent it from happening again. Instead, a more productive way to react to medical errors is to use justification as a means of learning and improving.

Justification involves taking responsibility for one's actions and acknowledging when a mistake has been made. This can promote a culture of accountability within healthcare organizations and encourage healthcare providers to take steps to prevent similar errors from happening in the future.

Also, by using justification as a means of learning, specialists can gain a better understanding of the factors that contributed to the error. They can develop strategies to prevent it from happening again. This can lead to continuous improvement and help organizations provide safer and more effective patient care.

Finally, justification is about understanding the reasons behind an error, rather than placing blame on any individual. This can help to create a blame-free culture within organizations, where healthcare providers feel comfortable with error reporting and working together to prevent them.

Suspension

And the third non-constructive approach is suspension. Distancing himself, the doctor attributes the mistake to the inevitable failure outcome: "Medicine is powerless here".

This approach excludes the emotional component and does not contribute to the development of a trusting relationship between the doctor and the patient. Consequently, it can have even greater negative consequences, including affecting the collection of important patient data and history, as well as affecting compliance with patient recommendations.

Why are these strategies unconstructive? The doctor cannot learn from his own negative experiences and perceive failure adequately.

What Should You Do Instead?

There are several ways doctors can learn from medical errors. First, you need to understand that your profession requires constant medical training and upgrading. Keep these steps in mind, and you'll see your quality improvement.

#1. Conduct a root cause analysis

Root cause analysis (RCA) is a systematic method used to identify the underlying causes of an event or problem. It is a valuable tool in healthcare for identifying and preventing errors from occurring again. Here are the steps to use RCA for avoiding mistakes:

• Identify the problem. What happened? Was it a medication error, a patient's fall, or any other event?
• Gather data. Collect as much data as possible about the event, including medical records, incident reports, and witness statements. Debrief all the information.

Implementing an EHR system in your practice can make the process of data storage and collection as simple as ABC. Keep all your patient information in one secure place and have easy access to it whenever you require it.

• Identify the causes. Use a fishbone diagram or another tool to identify all the possible causes of the event. This could include equipment failure, communication breakdowns, or human error.
• Determine the root cause. Was the primary reason for the event a lack of training, faulty equipment, or flawed processes?
• Develop corrective actions. This may involve revising policies and procedures, improving communication, or providing additional medical education.
• Track the effectiveness of the corrective actions and monitor the event to ensure it doesn't happen again.

In this case, the special module for reports and analytics in the PMS can come in handy. By means of the software, you can easily track your performance and create visual reports at a glance.

#2. Resolve the situation, or apologize

Well, it sounds great, but what if the situation is serious, and it can’t be resolved at once? Then apologize for what can be forgiven and strive not to repeat the mistake.

Apologizing for a mistake can help to restore trust between the doctor and the patient, and can also contribute to preventing the mistake from escalating into a larger issue. A sincere apology can help a long way in mitigating the patient harm caused by a mistake and can demonstrate that the doctor takes responsibility for their actions.

In some cases, an apology can help to prevent a lawsuit or can serve as evidence of remorse in court. Many states in the US have enacted "apology laws" which protect clinicians who apologize from having their apology used against them in court.

However, it is imperative for doctors to be careful about how they apologize for a mistake. They need to avoid admitting fault or liability, as this can have legal implications. Instead, doctors should focus on expressing empathy for the harm caused and a commitment to taking steps to prevent similar mistakes from happening in the future.

#3. Participate in peer review and case review discussions

Participating in peer review and case review discussions is crucial to avoid errors in medicine for several reasons.

First, it promotes critical thinking. By evaluating different cases and sharing their perspectives, healthcare professionals can identify potential errors, improve their decision-making skills and competencies, and develop a more thorough understanding of medical conditions.

Second, case review discussions bring together healthcare professionals from different specialties and backgrounds, medical schools and emergency departments, encouraging collaboration and knowledge-sharing.

And finally, it improves patient outcomes.

#4. Implement systems to improve patient safety

We have already mentioned the significance of PMS and EHR in building reports, analysing and storing data. Using these systems can also facilitate your daily workflow, making your appointments more convenient.

How does it work?

Practice management software gives you a range of pre-made protocols, checklists, consultation notes templates and a convenient reporting system. Moreover, there are no restrictions on any specialties. Whether you're a GP, a psychologist, a physical therapist, there are features for you.

Features like telemedicine and medical CRM make your doctor-patient relationships simpler to track and enhance.

Overall, using modern systems increases patient satisfaction and diminishes the chances of errors in your practice.

#5. Take care of your mental state

What’s done is done. You’ve made a mistake, analysed it, and learnt from it. You’ve done a great job and fixed the bugs. But you can still feel empty and drained. You can have such emotional responses to your mistakes as shame, grief, astonishment, sorrow.

That’s the right time to seek professional help from a psychologist and consider taking a vacation.

In the UK, doctors who are struggling with their mental health can access professional help through a range of support services, including:

• NHS Practitioner Health Programme (PHP). NHS PHP provides confidential support, advice, and treatment for doctors and dentists who are experiencing mental health and addiction problems.
• The British Medical Association (BMA) Counselling Service offers a free and confidential counselling service to members who are experiencing personal, emotional, or work-related problems.
• The General Medical Council (GMC) Support Services offers a range of support services for doctors, including access to confidential counselling, coaching, and mentoring. They also offer a confidential helpline for doctors who are in distress or need support.
• Doctors' Support Network (DSN) is a charity that provides peer support, advice, and information to doctors who are experiencing mental health problems.
• Local Occupational Health Services can provide confidential advice and support to doctors who are experiencing work-related stress or mental health problems.

There are many programs that can help professionals in trouble. It's helpful to know that seeking help is a sign of strength, and there is no shame in reaching out for support when needed.

Summing It Up

Learning from medical errors is a critical component of improving patient safety. By fostering a culture that encourages the reporting and analysis of errors, healthcare professionals can identify the root causes of errors. In addition, they can develop strategies to prevent them from occurring in the future. It is a must for clinicians to embrace a mindset of continuous learning and improvement, and to work collaboratively to create safer environments for patients.

By taking a proactive approach to learning from errors, medical professionals can improve patient outcomes, reduce healthcare costs, and ultimately save lives.

And finally, they look the patient and his loved ones in the eye and honestly say:

"I have done everything in my power".