A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I’m afraid that’s exactly what it was
BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1617 (Published 08 April 2019) Cite this as: BMJ 2019;365:l1617
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As medical staff we live in fear every single day, every waking minute in the hospital, of making a mistake. This is even more pronounced when you work as junior doctor and you don’t have the experience to fall back on the way your seniors do. You find yourself in situations where you are newly qualified, have reversed your sleep-wake cycle, worked back to back night shifts feeling tired, unsupported and under immense pressure. These kinds of hours have been proven to cause decreased cognitive function (Lingenfelser et al, 1994). Is it foolish not to expect there to be an increase in mistakes too?
Our hours make us more likely to make errors. The stressful environment and the nature of our work pave the way to us making errors. The fact that we are expected to be in multiple places at once and be at the top of our game every second of the working day is pressure that surely leads to errors. This is the reason we have protocols and guidelines. It’s why a radiologist and then a radiographer review your scan request before you send someone to CT. It’s why several different people ask a young female patient if she could be pregnant before they x-ray her. It’s the reason there is a guidance and safety standard for the insertion of chest drains, why there are multiple points of patient identification before we transfuse blood products and it’s why we count our surgical swabs in fives and mark them on a whiteboard.
At the end of the day, despite the fact we are viewed by most as the cogs in a never-ending, never-pausing machine, we are human beings. If you ask anyone – the public, managing staff of health boards, admissions teams at medical schools – what makes a good doctor then you’ll find the list of traits they come up with to consist of things like empathy, compassion etc. These are things that humans are capable of in ways that no machine ever will be. One of the side effects of being human is the inevitability of human error. We should be able to trust the protocols put in place to protect us from having to go through the embarrassment and the “cop out” of blaming our mistakes on human frailty.
Competing interests: No competing interests
I think despite the embarrassment, it might be worth sharing the nature of the error as it might help another practising radiologist.
I also wonder if anonymised radiographic images should be uploaded to an online forum soon after being taken. This would allow multiple experts to feed in their opinions should they wish to, and provide the radiologist with valuable second opinions and another opportunity to catch errors of inattentiveness / oversight. The image could be uploaded with the diagnosis and relevant observations with an instant comment section below for radiologists across the international community to either support the findings, or to make their own suggestions.
Competing interests: No competing interests
Re: A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I’m afraid that’s exactly what it was
I would like to thank the author for an illuminating and critical reflection on human error. While the author's reflection is personal and somewhat self-incriminatory, it stops short of analysing the full spectrum of 'human factors' which not only concerns the individual but also the team and the system.
Establishing the root cause might be attributable to the individual at first glance. But on further reflection, more questions could be asked about the role of the team and system in either prevention or mitigation. What is the role of audits and discrepancy meetings? Otherwise, how could we know the extent of these errors? Would it be possible to have an artificially intelligent (A.I.) system to scan for errors? How do we deal with the consequences of any failures?
The critical nature of our reflections needs to extend beyond the individual's role into teams and systems. Surely, this is relevant in the 'post-Baba Garwa' era where the practice of such reflective writing has come under scrutiny by those who would willingly attribute most, if not all, errors to the individual. If the ultimate purpose of reflection is to improve patient care, then should we not move swiftly from ruminations on the fallacies of inevitable human failure to other solutions such as system change, technology and A.I. solutions?
Competing interests: No competing interests