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Every physician knows that we learn more from our personal mistakes than our successes. But the total burden of error felt by our patients is but a small percentage of what an individual physician will see in practice. How can we all begin to learn from the mistakes of others?
Medical error reporting remains a sensitive topic for physicians, institutions, and patients. In a profession where the individual and collective expectation is infallibility, it is decidedly unnatural for physicians to share their personal medical mistakes. In fact, physicians who do share personal medical errors with their peers do so for altruistic reasons only. There is certainly no financial or academic benefit to publicly admitting your mistakes. However, the shroud of secrecy that continues to surround medical error deprives health care providers of knowledge that may help prevent similar adverse outcomes for patients in the future.
Although reporting individual medical mistakes to involved patients is obligatory by most professional codes of conduct for physicians, no laws or professional society guidelines mandate widespread reporting of errors to professional colleagues. In addition, one of the unintended effects of the patient safety movement is the de-emphasis of any individual physician culpability. In an effort to create a "blameless" culture, physicians have been told that the majority of errors are the results a flawed health care system. In a surprisingly passive voice, the Joint Commission has stated repeatedly that medical error reduction is fundamentally an information problem. Dr. Dennis O’Leary, former president of the Joint Commission, famously said, "The solution to reducing the number of medical errors resides in developing mechanisms for collecting, analyzing, and applying existing information."
As a result, significant attention and resources have been placed on health care systems and the identification and elimination of the organizational weaknesses that contribute to the individual mistake. Yet, there is no escaping the reality that virtually all errors involve the active failure of someone – not something – at the point of health care delivery.
It is within this context that I propose we turn our attention to the medicolegal system.
As a physician involved in peer review both within and outside the legal system, I have reviewed cases where bad outcomes have occurred. While I would prefer to tell you that every case was an unavoidable complication or the adverse patient outcome was predetermined in some fashion, that would be untrue. I have seen examples of flawed diagnostic or therapeutic decision making by individual physicians. And while the physicians involved routinely deny wrongdoing and confidently declare that if the circumstances were to repeat themselves, they would do nothing differently – I know and they know, that is untrue.
Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. Certainly, we begin with the understanding that an unexpected or untoward event has occurred. However, if we do our best to put ourselves in the position of the providers, knowing the facts as they were available at the time, we do have an opportunity to critically evaluate the decision making process. How thorough was the differential diagnosis? Was there confirmation bias? Did the physicians involved perform and/or document the expected history and physical examination?
Hospitalists today are extremely busy multitaskers facing increasingly complex and acutely ill patients. I believe there are invaluable lessons to be gained by walking in the shoes of those who have fallen into the maladaptations of heuristic thinking. Beginning next month, there will be a new column titled "Medicolegal Lessons." I will present a case vignette that will explore some aspect of medicine and the applicable standard of care. I hope to bring a critical emphasis on how physicians think and make decisions, with the ultimate goal of highlighting the lesson to be learned by all.
The more we share in our collective failures, the less likely we will repeat those same mistakes.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.
Every physician knows that we learn more from our personal mistakes than our successes. But the total burden of error felt by our patients is but a small percentage of what an individual physician will see in practice. How can we all begin to learn from the mistakes of others?
Medical error reporting remains a sensitive topic for physicians, institutions, and patients. In a profession where the individual and collective expectation is infallibility, it is decidedly unnatural for physicians to share their personal medical mistakes. In fact, physicians who do share personal medical errors with their peers do so for altruistic reasons only. There is certainly no financial or academic benefit to publicly admitting your mistakes. However, the shroud of secrecy that continues to surround medical error deprives health care providers of knowledge that may help prevent similar adverse outcomes for patients in the future.
Although reporting individual medical mistakes to involved patients is obligatory by most professional codes of conduct for physicians, no laws or professional society guidelines mandate widespread reporting of errors to professional colleagues. In addition, one of the unintended effects of the patient safety movement is the de-emphasis of any individual physician culpability. In an effort to create a "blameless" culture, physicians have been told that the majority of errors are the results a flawed health care system. In a surprisingly passive voice, the Joint Commission has stated repeatedly that medical error reduction is fundamentally an information problem. Dr. Dennis O’Leary, former president of the Joint Commission, famously said, "The solution to reducing the number of medical errors resides in developing mechanisms for collecting, analyzing, and applying existing information."
As a result, significant attention and resources have been placed on health care systems and the identification and elimination of the organizational weaknesses that contribute to the individual mistake. Yet, there is no escaping the reality that virtually all errors involve the active failure of someone – not something – at the point of health care delivery.
It is within this context that I propose we turn our attention to the medicolegal system.
As a physician involved in peer review both within and outside the legal system, I have reviewed cases where bad outcomes have occurred. While I would prefer to tell you that every case was an unavoidable complication or the adverse patient outcome was predetermined in some fashion, that would be untrue. I have seen examples of flawed diagnostic or therapeutic decision making by individual physicians. And while the physicians involved routinely deny wrongdoing and confidently declare that if the circumstances were to repeat themselves, they would do nothing differently – I know and they know, that is untrue.
Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. Certainly, we begin with the understanding that an unexpected or untoward event has occurred. However, if we do our best to put ourselves in the position of the providers, knowing the facts as they were available at the time, we do have an opportunity to critically evaluate the decision making process. How thorough was the differential diagnosis? Was there confirmation bias? Did the physicians involved perform and/or document the expected history and physical examination?
Hospitalists today are extremely busy multitaskers facing increasingly complex and acutely ill patients. I believe there are invaluable lessons to be gained by walking in the shoes of those who have fallen into the maladaptations of heuristic thinking. Beginning next month, there will be a new column titled "Medicolegal Lessons." I will present a case vignette that will explore some aspect of medicine and the applicable standard of care. I hope to bring a critical emphasis on how physicians think and make decisions, with the ultimate goal of highlighting the lesson to be learned by all.
The more we share in our collective failures, the less likely we will repeat those same mistakes.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.
Every physician knows that we learn more from our personal mistakes than our successes. But the total burden of error felt by our patients is but a small percentage of what an individual physician will see in practice. How can we all begin to learn from the mistakes of others?
Medical error reporting remains a sensitive topic for physicians, institutions, and patients. In a profession where the individual and collective expectation is infallibility, it is decidedly unnatural for physicians to share their personal medical mistakes. In fact, physicians who do share personal medical errors with their peers do so for altruistic reasons only. There is certainly no financial or academic benefit to publicly admitting your mistakes. However, the shroud of secrecy that continues to surround medical error deprives health care providers of knowledge that may help prevent similar adverse outcomes for patients in the future.
Although reporting individual medical mistakes to involved patients is obligatory by most professional codes of conduct for physicians, no laws or professional society guidelines mandate widespread reporting of errors to professional colleagues. In addition, one of the unintended effects of the patient safety movement is the de-emphasis of any individual physician culpability. In an effort to create a "blameless" culture, physicians have been told that the majority of errors are the results a flawed health care system. In a surprisingly passive voice, the Joint Commission has stated repeatedly that medical error reduction is fundamentally an information problem. Dr. Dennis O’Leary, former president of the Joint Commission, famously said, "The solution to reducing the number of medical errors resides in developing mechanisms for collecting, analyzing, and applying existing information."
As a result, significant attention and resources have been placed on health care systems and the identification and elimination of the organizational weaknesses that contribute to the individual mistake. Yet, there is no escaping the reality that virtually all errors involve the active failure of someone – not something – at the point of health care delivery.
It is within this context that I propose we turn our attention to the medicolegal system.
As a physician involved in peer review both within and outside the legal system, I have reviewed cases where bad outcomes have occurred. While I would prefer to tell you that every case was an unavoidable complication or the adverse patient outcome was predetermined in some fashion, that would be untrue. I have seen examples of flawed diagnostic or therapeutic decision making by individual physicians. And while the physicians involved routinely deny wrongdoing and confidently declare that if the circumstances were to repeat themselves, they would do nothing differently – I know and they know, that is untrue.
Medicolegal review has the opportunity to become the morbidity and mortality conference of the modern era. Certainly, we begin with the understanding that an unexpected or untoward event has occurred. However, if we do our best to put ourselves in the position of the providers, knowing the facts as they were available at the time, we do have an opportunity to critically evaluate the decision making process. How thorough was the differential diagnosis? Was there confirmation bias? Did the physicians involved perform and/or document the expected history and physical examination?
Hospitalists today are extremely busy multitaskers facing increasingly complex and acutely ill patients. I believe there are invaluable lessons to be gained by walking in the shoes of those who have fallen into the maladaptations of heuristic thinking. Beginning next month, there will be a new column titled "Medicolegal Lessons." I will present a case vignette that will explore some aspect of medicine and the applicable standard of care. I hope to bring a critical emphasis on how physicians think and make decisions, with the ultimate goal of highlighting the lesson to be learned by all.
The more we share in our collective failures, the less likely we will repeat those same mistakes.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.
