Fillers A salutary lesson

Learning from our mistakes

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7177.177 (Published 16 January 1999) Cite this as: BMJ 1999;318:177
  1. Kathy Ryan, former clinical assistant in accident and emergency
  1. Birkenhead.

    I made a mistake recently. I was working as a clinical assistant in accident and emergency and I missed a fracture. I missed it because I did not x ray the injured digit; I did not believe it to be fractured clinically.

    I was doing the dressing clinic when the sister appeared to warn me of a patient outside who was “hopping mad,” having been sent for an x ray examination by his GP. Pull the card, I said, feeling philosophical until I saw my own handwriting from seven weeks earlier. Should she get someone else to see him, asked the nurse. I resisted the temptation. The patient, a young man, was extremely angry. “Nothing personal, but I'm going to sue you.” I apologised profusely and said that I had made a mistake. I alerted my consultant who took over, reiterated apologies, and arranged a speedy hand clinic appointment. I kicked myself and mentally shelved it, awaiting the lawyers' communication.

    Three weeks later another sister said that a Mr X was outside wanting a word with me. I recognised the name. But contrary to my expectations he was not seeking to further vent his spleen. He said that he had realised that we all make mistakes and that he was not going to take it any further. He even apologised for getting so angry.

    I think his change of heart was partly due to marked clinical improvement, but there is no doubt in my mind that an important factor was that he had encountered the guilty party, received a sincere and unreserved apology with no excuses, and prompt remedial action had been taken. Isn't this what most patients and their relatives want when a mistake is made?

    Last year I initiated a teaching session for our senior house officers on complaints and mistakes. I felt that the whole issue of medical mistakes was either sensationalised or brushed under the carpet. No one seemed to look straight at the subject—what sort of mistakes are made? Why do we make them? What should you do when you've made one, and, as a result, how can they be best avoided and their consequences minimised? Everyone who came to the session had to bring a mistake they had made.

    It is not easy to admit that you have screwed up, especially when the outcome has been poor, but if we, and younger doctors, and medical students are really to learn from our mistakes, then I think a bit more honest discussion is needed. The BMJ could do a “Mistake of the Week” slot. I am sure that, along with the obituaries, it would be well read.

    We welcome articles of up to 600words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied on a disk. Permission is needed from the patient or a relative if an identifiable patient is referred to. We also welcome contributions for “Endpieces,” consisting of quotations of up to 80words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.

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