Dr Michael Devlin
When mistakes happen in medicine, it's important to know how to respond – and how to learn from the incident for the future. Dr Michael Devlin explains.
Mistakes by doctors are common. The National Reporting and Learning system (NRLS) receives over two million reports of incidents each year from the NHS in England alone.
Medical errors are mistakes by healthcare staff that have harmed a patient or put their safety at risk. These can include situations where harm has occurred (such as wrong-site surgery), or where harm may occur in the future following a medical error (such as an error resulting in foetal ischaemia, where there is no clear sign of brain damage after birth but where problems may become apparent years later) and circumstances where harm could have occurred but was prevented (such as a mix-up in blood samples resulting in a 'near-miss' of blood-type incompatibility, but which was noticed by vigilant staff).
As a medical student you will rarely be responsible for a medical error as an individual, as you will be working under supervision.
Where problems do arise, they tend to reflect poor communication skills or lack of experience, such as inadvertent breaches of confidentiality, not recognising the importance of consent when examining patients or taking blood from them, or working outside the scope of your competence. While these incidents are not unique to medical students, it's important to know how to deal with them and where to get advice.
Responding to medical error
Consider the venepuncture scenario below in the context of learning from errors. Ask yourself the following:
- What went wrong?
- Why did it go wrong (individual factors and systems factors)?
- What could be done differently to prevent a future recurrence?
Jim is a final year student. While working at an endocrine outpatient clinic, the consultant asks him to take blood from a woman with thyroid disease. Jim takes the patient to an adjacent room, having told the consultant that he has taken blood many times in the past and is comfortable doing so without supervision. There is no chair in the treatment room, and Jim asks the patient to sit on the edge of the examination couch.
Jim chats to the patient while taking blood, to put her at ease as she says she hates needles. He loses concentration and leaves the tourniquet on throughout, and having withdrawn the needle from the vein, blood squirts out and unfortunately the patient faints.
She falls from the couch and hits her head on the hard floor. Jim calls for help, which quickly arrives. The patient suffers bruising and swelling to her forehead, but no lasting damage.
Interpreting the error
The most obvious error made was not asking the patient to lie on the couch or sit in a chair to prevent a fall in the event of a faint.
The 'why' is a more difficult question to answer, and that is not unusual where errors are investigated because information about causes may be incomplete. From the scenario it isn't possible to know what the student's training in venepuncture had been. Might there have been a teaching failure within the medical school to emphasise the importance of making sure the patient is placed in a safe position at the start of the process?
As for learning and prevention – you probably identified that further training for Jim would be appropriate – but is it enough? Should there be a review of how venepuncture is taught; should the guidance on supervision be reviewed; should outpatient facilities have dedicated areas for venepuncture if it is to be carried out there?
Process for reporting a medical error
The patient should receive an apology, be told what went wrong and what actions are being taken to prevent this happening. The clinic consultant would most likely be the person to do this, but it could be useful for Jim to attend, both to offer a personal apology for what happened and also to see how events are explained in a clear, open way.
Tips for responding to errors
Given that there are over two million reports of incidents in the NHS each year alone, it goes without saying that in the future you are likely to be involved in an investigation into an error. Whatever form the investigation takes – and it ranges from a root cause analysis to a medical disciplinary investigation – you should feel supported. Nevertheless, it can be worrying and difficult to know how to put together a comprehensive account of your involvement, so don't hesitate to seek advice from the MDU, as well as from your educational supervisor or consultant in charge. The following five golden rules may be useful to keep in mind if you find yourself having made an error.
- Be honest. Never try to cover up an error by changing clinical records or putting a positive gloss on what happened.
- Tell someone you have made an error as soon as you can. This increases the chances that things can be put right for the patient. It also allows for the incident to be properly reported, investigated and learnt from.
- Apologise to the patient. It's the right thing to do, it will be appreciated by the patient and it may prevent the incident escalating into a complaint.
- Write an account while events are fresh in your mind. Contact the MDU for advice on how to put together an appropriate statement of events.
- Don't spend time ruminating on what happened; instead think about what you would do next time to prevent a reoccurrence.
The final stage in the process is an important one: reflect on what happened. If you feel upset or vulnerable, speak to someone; don't bottle it up. The fundamentally important message to take away is that errors do occur and you will improve your skills as a doctor by responding positively to mistakes, learning from them and continually improving.
More examples of medical error
A student downloaded some patient files onto his laptop for a research paper he was putting together. Unfortunately, the laptop was stolen and the student was concerned about the data getting into the wrong hands.
Check your university and hospital data protection policy to make sure you've fully complied with it and inform your supervisor and the police of the theft. If the files contain identifiable data, you may need to report the loss to the Information Commissioner. Don't store patient information on your own portable devices like laptops, phones or memory sticks.
A third-year student contacted the MDU concerned that he had been asked to catheterise a patient. He was unsure how to do so, and so watched a YouTube video. During the consultation, he casually remarked to the patient that this was his first time performing the procedure so he had watched a video beforehand. Although he successfully performed the procedure, the patient complained.
Students have an ethical duty to understand the limits of their competence and when to seek advice.
While it's important to learn how to perform procedures, you should be properly supervised when doing so and make sure that patient has given their consent. You should certainly not feel pressurised to do so if you are not competent. Make it clear to your supervising consultant/colleague that you are willing to learn and will either watch someone undertake the procedure, or do it yourself under supervision.
Dr Michael Devlin
Head of professional standards and liaison
Mike was an MDU medico-legal adviser for 15 years, latterly as head of medico-legal services, before taking up the new role of head of professional standards and liaison. He sat on the FFLM’s academic committee and was previously treasurer, and an examiner for the MFFLM. He has published widely on medico-legal matters, and has significant experience in teaching and assessing knowledge in medico-legal subjects.
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