http://bmj.com/cgi/content/full/323/7312/570
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Letters
Medical errors and medical culture
There
is no easy way around taking responsibility for mistakes
Pain
relief should have been provided without hesitation
Move
from"I" to "we" represents a paradigm shift in
responsibility
Changing
the culture of blame requires a revolution
There is no easy way around taking
responsibility for mistakes
The
case commented on by Singer, Wu, Fazel, and McMillan is chilling in that the
patient died in pain and suffering, and in the way it was handled by
the senior attending physicianswept
under the carpet, information falsified, and given a high minded sort
of dismissal with "let this be a lesson."1 That is
almost obscene.
The commentaries addressed most of the important points except discussing
the fear of litigation and the fact that there are no easy answers
when it comes to making mistakes. That needs to be said outright
lest someone, especially someone in training who is less
experienced, think that admitting a mistake stops at quality control
or sharing responsibility, and that there is then some way around
the difficult task of actually taking responsibility for the mistake.
Within the culture of medicine and even more broadly in modern society there
seems to be a drive for finding the easy way out. In this case there
is none, and it needs to be made very clear that this is a defining
moment in the life of a physician with regard to integrity and
professionalism. That must be included in the discussion of how a
supervising physician deals with a trainee who has made a mistake,
which was relayed with such insight and sensitivity by Wu.
Laurie Lyckholm
Department of Internal Medicine, Virginia Commonwealth University, Box
980230, Richmond, VA 23298-0230, USA lyckholm@vcu.edu
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1. |
Singer PA, Wu AW, Fazel S, McMillan J. Medical errors and
medical culture. BMJ 2001; 322: 1236-1240 |
Pain relief
should have been provided without hesitation
Large
myocardial infarctions in elderly patients are often fatal, and whether or not
earlier treatment would have resulted in the patient surviving will
never be known. What can be said with certainty is that the patient
mentioned in the education and debate section by Singer, Wu, Fazel,
and McMillan suffered a terrible death, and with or without the
results of the electrocardiogram the quality of the patient's life
for the last five days could have been greatly improved.1 "On
the next round the patient was still in severe pain
. . . We hesitated about whether to provide pain
relief."
An uncommunicative patient is in severe pain, and the doctors hesitate to provide
pain relief? Why, when the patient was so clearly, obviously, and
distressingly in pain? Cautiously initiating treatment with opioids,
and carefully adjusting the dose could have done much to have
alleviated the patient's suffering. Such palliative treatment could
also have done much to improve the patient's chance of survival.
As well as overlooking an errant electrocardiogram, an even more egregious
error was the failure to observe a dictate that serves as the basis for
compassionate care: To cure whenever possible. To comfort always.
Stephen Workman
Dalhousie University, Department of Medicine, Division of General Internal
Medicine, Halifax Nova Scotia, Canada B3H 2Y9 sworkman@is.dal.ca
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1. |
Singer PA, Wu AW, Fazel S, McMillan J. Medical errors and
medical culture. BMJ 2001; 322: 1236-1240 |
Move
from"I" to "we" represents a paradigm shift in
responsibility
Singer,
Wu, Fazel, and McMillan present a case of medical error and cover up with
thoughtful commentary.1
Wu, however, inadvertently illustrates just how difficult to achieve
the change in culture required to "learn to love mistakes"
will be. He suggests how the doctor concerned should explain the
mistake to the relatives of the woman who has died: "I regret to
say that we made a mistake in your relative's care
. . . we missed signs of what was probably a heart
attack . . . I am devastated at being responsible for this,
and can only tell you how sorry I am."
This statement illustrates both a desire to promote corporate responsibility
for medical errorswe
made a mistakeand
a requirement that physicians take full personal responsibility for
suchI
am devastated at being responsible. I think that these two ways of
seeing medical errors are incompatible; the move from "I" to
"we" represents a paradigm change. The reconceptualisation
of medical error as a corporate or "systems failure"
necessitates a change in the way that physicians attribute guilt for
error to themselves. In the case discussed the junior physician clearly
believes responsibility for the error is his or hers.
This may well be a true belief. But it is not justified by the related facts
of the case. A statement to relatives that "I am devastated at
being responsible" would not be justified until the contribution
of overwork, underfunding, and general NHS chaos had been
investigated. If medical error is to be considered a failure of
systems the justification for responsibility on the part of the
physician could only arise as the result of investigation by the
corporate entity involved. To encourage reporting of medical error
the language of ethical commentary cannot drift between the
"I" and the "we" paradigms. Ethicists must be consistent in
their use of language in this debate. Corporate responsibility for
medical error offers many advantages and is to be encouraged. It
cannot operate unless physicians are encouraged to stop blaming themselves
in a peremptory fashion for every calamity that befalls their organisation.
Wayne Lewis
Carreg Wen Surgery, Blaenavon, Gwent NP4 9AF wayne@drlewis.freeserve.co.uk
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1. |
Singer PA, Wu AW, Fazel S, McMillan J. Medical errors and
medical culture. BMJ 2001; 322: 1236-1240 |
Changing the
culture of blame requires a revolution
I
read with interest the series of articles on medical errors and medical culture
by Singer, Wu, Fazel, and McMillan.1 I
fear that without a revolution in the culture of blame within medicine
things are unlikely to change. I believe the revolution we need is
for individual doctors to be indemnified from personal blame after a
medical mishap if the following conditions are adhered to. He or
she, firstly, immediately communicates the mishap that has occurred
to all necessary parties (including the patient); secondly, takes
immediate necessary steps to neutralise or limit any harm; thirdly,
then engages fully with critical analysis of the incident and the
implementation of any remedial programme or training necessary.
The organisation for which that doctor works would remain accountable for
the system under which the mistake occurred, leaving the patient
with an appropriate avenue for financial redress, if justified.
Should a pattern of multiple or recurring mistakes occur with a
given doctor, this would still leave the employing organisation and
any other interested party (General Medical Council, Commission for
Health Improvement) with justification for action. This is not
because of any individual error but because of a worrying pattern of
apparent inability to learn from previous mistakes and benefit from
remedial input.
Although I can offer this as an alternative vision, I am not clear how to
achieve the seismic change in political, professional, and societal
attitudes that would be necessary to move from our present position
to the one I propose.
Brendan Harrington
Wrexham Maelor Hospital, Wrexham LL13 7TD
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1. |
Singer PA, Wu AW, Fazel S, McMillan J. Medical errors and
medical culture. BMJ 2001; 322: 1236-1240 |
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Other related articles in
BMJ:
EDUCATION AND DEBATE
An ethical dilemma: Medical errors and medical culture • An error of omission • Commentary: Learning to love mistakes • Commentary: Doctors are obliged to be honest
with their patients •
Commentary: A climate of secrecy undermines public trust.
Peter A Singer, Albert W Wu, Seena
Fazel, and John McMillan
BMJ 2001 322: 1236-1240.
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