The world of hospital medicine is challenging, varied, stimulating and sometimes terrifying. It can be immensely rewarding to work as part of a team, contribute to a patient’s diagnosis and watch as their clinical condition improves. But, of course, not every day goes well, not every patient improves and sometimes mistakes are made. One of the greatest challenges a doctor will face during their career is in ensuring they respond well when things go wrong. Even the most experienced doctors make mistakes but it can be particularly difficult to deal with when you are one of the more junior members of the team.
The impact on doctors of making an error has been recently demonstrated by Harrison et al (2014) in their online survey of members and Fellows of the Royal College of Physicians. Of 1,755 respondents, the survey found that 76% felt personally or professionally affected by adverse patient safety events and 25% reported that they did not report an incident when they knew they should have done so. The impact of an adverse event included an increase in stress and anxiety, disturbance in sleep, reduced satisfaction at work and a fear of punitive action.
So how should you deal with an adverse incident? What are your professional obligations when a mistake is made? How is your hospital likely to investigate and where can you go for support when something goes wrong?
The GMC sets out in Good Medical Practice (2013), the need to be open and honest with patients when things go wrong, to put matters right (where possible) and offer an apology with a full and prompt explanation.
More recently, the GMC has set out new guidance in Openness and Honesty when things go wrong which highlights that all healthcare professionals have a duty of candour. You have a duty to be open and honest with patients in your care, or those close to them, if something goes wrong and to apologise when this occurs.
As a junior member of the team it can be daunting to consider trying to explain when something goes wrong. The GMC states: “We don’t expect every team member to take responsibility for reporting adverse incidents and speaking to patients if things go wrong. However we do expect you to make sure that someone in the team has taken on responsibility for each of these tasks, and we expect you to support them as needed.”
It is recognised that the lead clinician is likely to be best placed to speak to the patient, and that this conversation should take place as soon after the mistake comes to light as possible. The patient should have a friend, relative or professional colleague present to support them and if the consequences of the mistake are not yet clear, this should be communicated to the patient. You may well be asked to accompany a more senior colleague to discuss an incident, and if you have been personally involved in making a mistake, should apologise for this during the conversation.
Where the harm caused has been so serious as to cause incapacity or death then the GMC states you must be open and honest with those close to the patient, answering any questions they may have and providing details of support available.
When near misses occur, you are obliged to consider whether it would be beneficial to the patient, or cause them harm, before discussing this with them. Seek advice from a senior colleague if you are unclear
When apologising, as well as saying “sorry” the apology should include an explanation of events and provide information to the patient about how any harm will be dealt with. The GMC states patients should also be told “what will be done to prevent someone else being harmed”.
Hospital incident reporting
All hospitals have processes for reporting incidents and you should know how to use these systems (which include reporting near misses). If a serious incident occurs, then hospitals in England and Wales are required to investigate these and produce a report within a 60 day period.
A serious incident involves those where an error results in unexpected or avoidable death, unexpected or avoidable injury (resulting in serious harm) and other incidents such as abuse and Never Events.
If you are involved in a serious incident, you are likely to be asked to contribute to the investigation, by providing a statement, attending an investigatory interview or both. If you know something has gone seriously wrong, it is preferable to draft a statement (see more below) as soon after the incident has occurred as possible, while events are still clear in your mind; there is no need to wait to be formally asked.
Duty of candour
The new statutory duty of candour came into force for hospital trusts in England and Wales in November 2014 and for all organisations registered with the CQC in April 2015. This followed the external inquiries into the Mid-Staffordshire NHS Trust scandal with Sir Robert Francis QC describing an NHS culture of cover up and denial when medical errors occurred.
Your GMC obligations require you to cooperate with this duty to be candid when your employer requests this. The duty of candour requires an organisation to ascertain whether a ‘notifiable safety incident’ has occurred (see Medical Protection: Duty of Candour), and if so, a process of discussion with the patient and documentation of the investigation and outcome of the incident must be completed. You could be asked to participate in this process, alongside the hospital investigation.
Practical steps & support
As soon as you become aware you have made a mistake (whatever its magnitude) or been involved in a serious incident, you should:
- Stop, acknowledge the mistake, decide whether you need to seek the advice of a senior colleague immediately to ensure the necessary steps are taken to minimise patient harm and investigate the error.
- Report the error using your hospital incident reporting systems if this has not already been done.
- Speak to the patient (and/or relatives) if you feel competent to do so and the error is minor, or with a senior colleague, if this is more appropriate (and in all cases where more complex discussion is likely to be needed). Remember the patient should have someone present to support them.
- Ensure you, or your senior colleague have apologised, both for any mistake made and/or any distress caused, have explained what has occurred and what is likely to occur next. Explain who the patient can approach if they have further questions and how the investigation will proceed.
- Document any discussion within the medical records.
- Discuss the incident with your educational and clinical supervisor and try to identify any learning points.
- Comply with your employer’s request to fulfil their obligations under their duty of candour, discuss this with a senior colleague if you are unsure.
- If the incident is serious and your involvement may be questioned, you should immediately draft a statement which factually sets out your involvement (see our factsheet on report writing for more information). Make sure you have access to the medical records when writing your statement and ensure it is factual and clearly sets out your involvement.