Observations Ethics Man

The hardest thing: admitting error

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3085 (Published 02 May 2012) Cite this as: BMJ 2012;344:e3085
  1. Daniel K Sokol, honorary senior lecturer in medical ethics, Imperial College London, and barrister, Inner Temple, London
  1. daniel.sokol{at}talk21.com

There should be no more closing of the ranks when medical errors occur. The interests of the wronged patient should trump those of the clinicians

Even the best close-up magicians make mistakes. They are, simply, unavoidable. Good magicians therefore prepare for mistakes by rehearsing alternative endings and memorising quips in case of irreparable failure: “The real magician will be here in a minute,” or, “It worked fine in the magic shop.” A friend of mine says, “At least if I make a mistake, no one dies.”

Doctors cannot use that line. Their mistakes can lead to serious harm. While a magician’s error is usually apparent to all, a doctor’s error can be difficult to spot, especially by those who are not medically trained. The patient is, after all, already unwell by the time of the doctor’s involvement. The first people who know that an error has occurred are usually the clinical team.

I remember speaking to a doctor who had been consulted by a couple with a severely disabled baby. On reading the medical notes, it dawned on her that the child had probably been subject to negligent treatment. The doctor nonetheless felt torn between her loyalty to her hospital colleagues and her desire to tell the truth to the couple. To my mind, this was not a moral dilemma. The doctor should have advised the couple to seek legal advice. It is hard to overstate how much of a difference an award of damages could make to a family. It could cover the astronomical cost of care and allow the family to find suitable accommodation or modify their homes. I wondered why the doctors at the hospital had not revealed the mistake to the family. What happened during that morbidity and mortality meeting when the trainee presented the case to the department? Did no one speak up on behalf of the family? Did no one realise that silence might condemn the family to decades of bitter struggle?

Kroll and colleagues remarked in a 2008 study of junior doctors’ accounts of errors that “we know remarkably little about the day-to-day management of medical error in the UK.”1 To find out more, the authors conducted interviews with 38 preregistration house officers. The authors identified a “strong sense of professional loyalty in which doctors, despite discomfort, kept quiet over others’ errors.” They also observed that “team feedback after error often prioritised reassurance: errors were normalised, dealt with through teasing, or minimised as being ‘not the juniors’ fault,’ ‘not serious,’ or ‘not a matter of life or death.’ Deaths after an error were often framed in the context of inevitability: the patient wouldn’t have made it anyway.” It is odd how doctors are reluctant to make prognostications in some contexts (“It’s not possible to give an accurate prognosis”) but quite willing to do so in others. In any event, it is not for the doctors to determine what would have happened in the absence of any error. As the source of the error, or close to it, they are at high risk of bias.

In another case a patient developed a swelling of the eye after endoscopic sinus surgery.2 A consultant assessed the patient and recommended conservative management. The eye got worse, and, despite an urgent decompression procedure, the patient lost the sight in his eye. The patient was told that the blindness was caused by air in the orbit. A registrar carefully explained how the air caused the damage to his optic nerve. The ophthalmic surgeons at the hospital published the case in a peer reviewed journal, describing the cause of the injury as air in the orbit. The patient eventually sued the hospital, which, remarkably, defended the case on the basis that the injury was caused by an infection rather than air in the orbit. The claim was settled in the patient’s favour, although the hospital did not admit liability. As the lawyers involved in this case note, the trust’s steadfast refusal to accept an error explains why “the public’s faith in the medical profession’s willingness to admit mistakes is somewhat jaded.”

The General Medical Council’s Good Medical Practice at paragraph 30 states that doctors should be open and honest when things go wrong: “If a patient under your care has suffered harm or distress, you must act immediately to put matters right if that is possible. You should offer an apology and explain fully and promptly to the patient what has happened, and the likely short-term and long-term effects.” A similar professional duty exists for lawyers. I will not tediously list the pros and cons of disclosure, nor will I dwell on the trite observation that admitting a mistake is painfully difficult for any self respecting professional. In this situation, ethics has a right answer: forget loyalty to colleagues, forget the reputation of the department, forget about standing and promotion, forget about what the patient or relatives will think, the patient (or, if not mentally competent, his or her relatives) must know if a harmful error has occurred. The patient can then decide what to do.

There should be no more closing of the ranks. The interests of the wronged patient should trump those of the clinicians. And for those doctors who disagree, who are willing to let injured patients and relatives suffer without any compensation or explanation to lighten the burden, who are unable to put themselves in the shoes of the victim, I recommend an alternative career in magic.

Notes

Cite this as: BMJ 2012;344:e3085

Footnotes

  • Competing interest: DKS is a member of the Zodiac Magical Society.

References

View Abstract