When things go wrong
One important aspect of being a professional is having sufficient knowledge and expertise to recognise when things are not going according to plan. In some cases this will be quite obvious: a misplaced pacing wire or a bowel perforation during colonoscopy. In some cases it may be less obvious: bile duct injury during laparoscopic cholecystectomy, or vascular injury during angiographic intervention leading to a false aneurysm. All these situations require a response based on three elements:
- The knowledge, experience and training to know that something is not quite right
- The integrity to discuss it openly and honestly with the patient
- A willingness to acknowledge that you are getting out of your depth.
Such a discussion is often the hardest part for anybody since nobody likes to admit to failure, getting things wrong or making avoidable mistakes. But that is all part of being a competent professional person and the patient is entitled to an honest appraisal of their situation.
Learning from mistakes An integral part of the educational process is learning, from experience, how to develop and improve your skills: we can all learn from our mistakes. A careful reflective analysis of how an error arose is the key to preventing its recurrence. In risk management this analysis is called root cause analysis. This is the process of finding and eliminating the fundamental cause that would prevent the problem from recurring; only when the root cause is identified and eliminated can the problem be solved. The purpose of root cause analysis is to ask:
- What happened?
- Why did it happen?
- What can be done to prevent it happening again?
A formal approach to recording these incidents is known as significant event audit (SEA). This technique can be used to celebrate good practice, as well as improving suboptimal practice. Take, for example, a patient who presents with a long-standing cough and recent haemoptysis. A chest x-ray shows a 5cm mass at the right hilum. When looking back at a previous chest x-ray done eight months earlier the right hilum is noted to be abnormally prominent and dense. Why was no action taken?
- Was it a system error – the radiographs were reported but the report was filed without being seen by the clinician?
- Was the abnormal report noted but not acted upon – eg, an appointment was never made (another system failure)?
- Did the radiologist see it but did not feel it warranted mentioning, or the clinician did not feel it warranted investigation?
- Did the radiologist fail to see the lesion?
With an open mind, the different possibilities described above could translate into a procedural rethink or, possibly, training needs for the doctors involved.