Learn or Blame: when mistakes happen in medicine

by Carolyn Thomas   ♥   @HeartSisters

Mistakes happen in medicine, just like in every other workplace. As intensive care physician and president of The Doctors’ Association UK (DAUK) Dr. Samantha Batt-Rawden reminded us in a BBC Newsnight interview:

“If patients are looking for a doctor who has never made a mistake, they simply won‘t find one.”       .          .         .

I first became intrigued by issues such as medical mistakes and diagnostic error after I was misdiagnosed in mid-heart attack (“You are in the right demographic for acid reflux!”) and then sent home from Emergency – despite textbook cardiac symptoms of central chest pain, nausea, sweating and pain down my left arm.

I’m no doctor, but even I knew at the time that left arm pain is not a symptom of indigestion. But I felt so embarrassed for making a fuss over “nothing” that I couldn’t get out of there fast enough.  By the time I was desperate enough to finally force myself to return to the same Emergency Department, I could not walk more than five steps, and I knew that the doctor who had cheerfully misdiagnosed my symptoms had been horribly wrong. My “widow maker” heart attack was appropriately diagnosed (this time, by a different Emergency doc).

Ever since then, I have been asking questions. Questions like, why are women like me significantly more likely to be misdiagnosed in mid-heart attack compared to our male counterparts?

Why are ambulances transporting female heart patients to the hospital less likely to use flashing lights and sirens than they do for male heart patients? 

Why have cardiac diagnostic tests, drugs and procedures been largely designed and researched for the past four decades on (white, middle-aged) men – yet women are still not equitably represented in clinic trials?(1)

We have few answers to most questions (although the history of women’s health care suggests that, as in other areas of our culture, implicit bias against female patients is pervasive).  

Here’s an example of this implicit bias, from cardiac researcher Dr. Karin Humphries in Vancouver, whose studies suggest a significant problem with the routine blood test for the cardiac enzyme called troponin – typically a reliable marker for heart muscle damage caused by a heart attack.(2)  But the commonly used troponin threshold in this test is based on a level that’s considered appropriate for men, but may be set too high for women – whose blood tests would then be interpreted as “normal”.  Dr. Humphries suggests that “setting a lower female-specific troponin threshold would improve the diagnosis, treatment and outcomes of women presenting to the Emergency Department.”   

This begs another question: how many women like me have been refused cardiac treatment because our troponin blood tests appeared to be “normal” – no matter how severe their cardiac symptoms were? 

To my knowledge, there is no requirement for mandatory reporting of diagnostic error in most healthcare systems – including here on the west coast of Canada. What stunned me most was learning that, because such errors are not reported, it means they never happened.  

If I had died after being turned away that day, my death certificate would have almost certainly read, under cause of death, “myocardial infarction” (heart attack). 

But that cause of death would have been wrong, as I wrote here

“The actual cause of my death would have been that I was misdiagnosed during a heart attack, denied appropriate care, and sent home from the Emergency Department.
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“Had a death occurred, the fact that I’d been earlier misdiagnosed in the same hospital and sent home might never have been reported, never reviewed at hospital rounds, never discussed with the medical director, never used as an important case study for med students, never considered as a teaching tool that might help prevent this type of cardiac misdiagnosis from happening to other women in the future – and certainly never recorded on a death certificate as the cause of my death.
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“And what a lost opportunity that would have been.” 

Physicians who argue against mandatory reporting of misdiagnosis or medical error seem united in a vague unwillingness to see this as a public safety issue. For example, even though the authors of the landmark Institute of Medicine report in 2015 called Improving Diagnosis in Healthcare concluded: “Urgent change is warranted to address this challenge”, they politely backed off from recommending mandatory reporting. 

Instead, here’s how the report’s committee chair responded to repeated media questions at the report’s official launch event in Washington, DC::

“Now is not the right time for mandatory reporting of diagnostic errors. Voluntary reporting efforts should be encouraged and evaluated for their effectiveness.”

How “effective” do you think these “voluntary reporting efforts”  are, six years later?

If voluntary efforts were actually effective, we would still have voluntary hard hat usage on construction sites, or voluntary speed limit laws on our highways, or voluntary safety checklists by airline pilots before takeoff. 

Studies (3,4) on the under-reporting of adverse medical events have blamed “powerful disincentives to impose mandatory reporting”. (Translation: “You can’t make me!”)

The healthcare field is alone among workplaces in that, when bad things happen to their end users, the knee jerk response is to hope that they’ll just go away quietly. See also: Saying the Word “Misdiagnosis” is Not Doctor-Bashing

Other occupations, by comparison, routinely require incident reports whenever a critical incident occurs on the job that has involved harm, potential harm or death.  This is a public safety issue, and addressing it is considered the prudent path to help prevent similar harms in the future.  Ignoring what has happened is not prudent. 

Healthcare professionals may fear that reporting errors means blame and punishment, not an opportunity to learn or to protect future patients from preventable harm. As HR consultant Michael Tims tells his clients, “The only thing people learn from being blamed is to become better at hiding their mistakes.”

Sometimes that fear might be justified – especially when individual healthcare professionals are sued or criminally charged for tragedies that can arguably be due to the way healthcare systems work. So individuals working hard on the front lines can worry that blame will fall upon them for harms that may be more accurately inevitable results of systemic issues.

Here’s an example of a hospital environment designed to cause errors, according to Emergency doc Dr. Terry Fairbanks, a human factors engineer-turned-physician who has studied human errors in medicine for decades. He describes how errors can happen in the case of a hospital nurse who gives medications to patients earlier or later than ordered:

“These errors can happen because in the 11 a.m.-1 p.m. time frame required to give all noon meds, for example, the nurse cannot possibly do it. From an industrial design perspective, the nurse is being forced to find a shortcut.”

Yet if something tragic happens as a direct result of that nurse’s “shortcut”,  the system itself won’t be sued, fired or criminally charged with negligence – but that individual nurse might be. 

Dr. Fairbanks (a Professor of Emergency Medicine at Georgetown University and Founding Director of the National Center for Human Factors in Healthcare) was first known as an expert in human performance, specifically in how to change systems to make that performance safer by addressing human errors and creating a culture of accountability. 

But health care, he warns, does something that other complex high-risk industries don’t do anymore when it comes to errors:

“We keep focusing on individual performance. We need to change our focus to reducing harm, not just reducing error. 

“In the 1970s, when we were trying to reduce human error in aviation and we were using the nuclear energy industry as our model, aviation experts told us, ‘It’s different – we’re not the same, you can’t apply this stuff to us!’ ”

It turns out that industries learn from each other’s experience in reducing workplace harm. Their singular focus on preventing future harm happens in the same fashion as workplace safety, highway safety, nuclear energy safety or aviation safety protocols that embrace mandatory reporting of critical incidents in order to help track these incidents.

How can anybody, anywhere continue to insist that patients do not deserve the same efforts at protecting us, too?

The Doctors Association of U.K. (DAUK) has launched #LearnNotBlame, a campaign they hope will result in what they call a “just culture” in Britain’s National Health Service. U.K. neurologist Dr. Jenny Vaughan, who in 2018 was awarded the British Medical Journal (BMJ) award for ‘speaking truth to power’, advocates for improvements to patient safety by working with DAUK.

As she says, 

“Health care needs an open and transparent culture where harm is minimized by learning from mistakes. Patient safety should always come first. We need to bring in a truly just culture so that all errors are discussed openly.”

Trying to pretend that errors which cause harm are not happening is neither open nor transparent.

(1) Editorial, The Lancet, “Cardiology’s Problem Women”;  Volume 383, Issue 10175, p959; March 9, 2019. 
(2) Zhao Y, Izadnegahdar M, Humphries KH et al. “High-Sensitivity Cardiac Troponin – Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women (CODE-MI)”.  Am Heart J. 2020 Nov; 229:18-28. 

(3) Vincent C. “Reasons for not reporting adverse events: an empirical study. ” J Eval Clin Pract. 1999; 5:1–9.

(4) Paul Barach et al. “Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.”  BMJ. 2000 Mar 18; 320(7237): 759–763.

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Q:  Are there any good reasons for NOT recommending mandatory reporting of diagnostic errors?

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♥ NOTE FROM CAROLYN:    I wrote much more about patient safety in my book A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press, 2017). You can ask for this book at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press (use their code HTWN to save 20% off the list price when you order).

See also: 

The science of safety – and your local hospital

Mandatory reporting of diagnostic error: “Not the right time!?”

“It’s not your heart. It’s just _____” (insert misdiagnosis)

Misdiagnosis: is it what doctors think, or HOW they think?

Seven ways to misdiagnose a heart attack

Misdiagnosis: the perils of “unwarranted certainty”

Cardiac gender bias: we need less TALK and more WALK

Unconscious bias: why women don’t get the same care men do

How can we get heart patients past the E.R. gatekeepers?

 

15 thoughts on “Learn or Blame: when mistakes happen in medicine

  1. I have a neighbor who has just returned from the Mayo Clinic in Arizona where she had a successful surgery and now feels so much better. She turned to the Mayo Clinic because she felt she wanted a second opinion about her medical issues. She has encouraged me to do the same.

    I have been diagnosed with Microvascular Disease because my Doctors don’t know what else to do with me. I am being urged by my neighbor to explore going to the Minnesota Mayo Clinic for a second opinion. I have had a quadruple bypass, 2 subsequent angiograms, one where a stent was put in. But I still have significant issues. I know you are not a DR. but you have had great experiences with the Mayo Clinic.

    If you have any thoughts I would appreciate you sharing them with me.
    Thanks. I love your weekly “Heart Sisters” blog.

    Ann Wheeler
    Salt Spring Island

    Liked by 1 person

    1. Hello Ann – I can only imagine how frustrating it must be to have your cardiac history of diagnostics and procedures – and still be having “significant issues”. It sounds like you might not be 100% sold on this microvascular diagnosis? I’m also curious if you’ve been seen by Dr. Tara Sedlak at Vancouver General Hospital (your GP can request a referral directly – more info here: http://www.drtarasedlak.com/faqs/ ). She’s undoubtedly the most experienced cardiologist on the west coast in the area of coronary microvascular dysfunction, and has done an additional training fellowship at Cedar Sinai Medical Centre in Los Angeles with Dr. Noel Bairey Merz, the world’s leading expert in women’s heart health, which made Dr. Sedlak the first Canadian cardiologist with such training credentials.

      If you haven’t yet seen her, you might consider a consult with Dr. Sedlak before booking a trip to Mayo. The Mayo Women’s Heart Clinic is a terrific option if you can afford it (although it’s a non-profit hospital, it’s certainly not free).

      Take care Ann and best of luck to you. . . ♥

      Like

  2. When I look back on my long nursing career and all the doctors and nurses I worked with, I can remember errors big and small that went unreported.

    Occasionally tragic… and I remember a patient in our ICU whose family filed a lawsuit while she was still in the ICU. I don’t think where I worked had any more errors than anywhere else but the culture was definitely one that did not encourage reporting.

    I believe there was an attitude of self-survival and misplaced camaraderie. Behind this culture with thoughts such as: ‘We are not perfect, all healthcare workers make a mistake once in a while. Usually the patient is not harmed. The public doesn’t understand, they expect us to be perfect and if not, they sue us and we lose job, license, and the ability to support ourselves. So we stick together and turn a blind eye unless it is TRULY malpractice and/or resulted in harm.’

    There is a certain amount of spiritual maturity that must be in place to recognize that the good of the greater population needs to be considered before our own personal fears. We are evolving, however. The large majority of people are still very ego/self-centered and have a hard time embracing a concept like mandatory reporting as anything but harmful to themselves.

    Liked by 1 person

    1. Hello Jill – I too suspect all of those excuses you mentioned are indeed involved in this reluctance to view errors (and especially misdiagnoses) as a public safety issue. It’s interesting to me that the first objection from clinicians so often sounds like “You don’t understand… Medicine is NOT like aviation or other fields… We couldn’t possibly track all these incidents…” But as I once heard the Pulitzer Prize-nominated ProPublica journalist Marshall Allen warn his audience at Stanford University’s Medicine X conference:

      “Until you start measuring something, you can’t improve it.”

      Sadly, litigation – particularly in the U.S. – can often seem like the only option once a patient has been harmed. There are many steps before that decision to sue (short of clear incompetence), however. For example, the medical apology is still surprisingly rare (despite many U.S. states passing comprehensive medical apology laws – meaning an “expressions of regret to a patient or that patient’s family” cannot be used as evidence in any future malpractice suit).

      This is tragic, as so many families say that’s all they wanted to hear. It’s rarely about the money (beyond income replacement or cost of future care awards). And as Dr. Judy Melinek warned her colleagues in MedPage Today:

      “Plaintiffs are more likely to settle a case if they like you and feel that you care, that you and the hospital administrators have learned from the mistake, and aren’t going to put others at risk..”

      I think you’re right, Jill – maybe it’s the word “mandatory” that clinicians do not and cannot accept….

      Take care, stay safe… ♥

      Like

      1. I had a heart surgeon who claimed he could handle my ventricular septal myectomy quite well and had been doing them for decades. Little did I know that he had not upgraded his knowledge of new techniques, so my surgery had a less than optimal outcome and had to be redone by experts at a Mayo Clinic a year later.

        My nurse attorney friend said suing was not a good bet, as I am alive and well so not suffering long term consequences. Time? Suffering? Financial drain? Recovery time? A year of my life wasted?

        I wrote a detailed letter to the surgeon about what I went through and to the cardiology department of Kaiser that referred me there. Kaiser stopped referring people to anywhere but Mayo for the surgery, but the surgeon never apologized to me.

        I only hope he decided to stop doing that procedure ( I guilted him heavily in my letter LOL) so that others would not have to undergo two open heart surgeries where only one is needed. I’m not sure where sub-standard care fits in the realm of mandatory reporting of errors. Just food for thought.

        Liked by 1 person

        1. Good grief. . . Call me cynical, Jill, but somehow I cannot quite believe that a cardiac surgeon could be “guilted” into volunteering on his own to no longer do a surgical procedure that he has bragged about being an expert at “for decades” – unless he was first forced into that decision by hospital admin.

          Yet your letter certainly did get results. Even if he WERE the sort of surgeon who could feel guilt, I’m thinking he would have offered a simple expression of regret (that’s NOT a real apology e.g. “I’m sorry that my actions hurt you”) – but more just: “I’m sorry you suffered through that…” But he couldn’t even do that.. 😦

          As Dr. Melinek would likely add, this surgeon’s personal decision (to ignore your letter) did NOT qualify as showing that he cares at all about you, BUT the fact that Kaiser is now referring future surgeries to Mayo may qualify as “hospital administrators have learned from the mistake, and aren’t going to put others at risk. . . ”

          One of my readers (like you, also an RN) once told me about a dreadful phone conversation she overheard at work between a physician colleague who had received one of those detailed letters from a patient complaining about a serious medical error. The colleague was on the phone with a friend, reading the patient’s letter aloud to his friend while “laughing and rolling his eyes” over every line she’d written. There’s a special place in hell for docs who are still practicing medicine with that attitude… Arrrrgh!

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          1. That surgeon seems to be quite competent at other open heart surgeries, but I found out later he only does myectomies once or twice a year. I still belong to Kaiser HMO and use the same hospital for other procedures. Every time I have a cardiac cath, I insist my cardiologist check to see who is on call for CV Surgery should there be an emergency …. because I will never allow that surgeon to come near me again!

            Liked by 1 person

            1. I don’t blame you! The troubling thing about that strategy is that a patient like YOU ( a nurse with good health literacy and related patient experience) is able to intervene on your own behalf to request (or deny) a specific surgeon. But the average emergency patient likely has zero clue who she’s being assigned, or how many procedures like the one she’s about to undergo the assigned doctor has successfully completed. And especially during an emergency, TIME IS MUSCLE so there’s simply no time to review references as your gurney is being wheeled upstairs…

              Once, an interventional cardiologist who was an early adopter of the wrist-access (“radial”) approach when implanting coronary stents told me that some interventionists (like himself, clearly implied) are excellent at mastering this procedure and prefer it to the old femoral (groin) access – less bleeding, fewer complications. “Some will NEVER be good at it!” he then added as if to confirm his own superior skills.
              .
              I repeatedly asked him how the average patient coming in from Emerg could possibly know if the cardiologist about to meet her in the cath lab for the first time was one of the “good” ones or the “never good” ones. He suggested to me that such patients should ask a cardiac nurse for an expert opinion. Again, I asked how the average heart patient who does not happen to know any cardiac nurses could reach such nurses? By now, I could tell he was irritated at this line of questioning, but honestly – unless you work in that hospital, or have prior knowledge as you did, or happen to have friends who work in the cath lab – we can’t just get the hospital switchboard operator to transfer our inquiry up to the cath lab so we can ask for a performance review. . . It wouldn’t have even occurred to me while being rushed from the ER to the OR for my first trip to the cath lab to even ask the doc who was about to implant my stent: “How many radial access PCIs have you successfully completed?” – given that I had no clue what even goes on in the cath lab at the time… 😉

              Like

              1. So true, my last 2 cardiac caths were scheduled, not emergent so I had a choice in scheduling.

                If they had been emergent the element of choice dwindles. As a nurse, I beat myself up a lot after my first heart surgery… I should have asked more questions of the surgeon. But REALLY should I have to? Would a “non-nurse” patient even know what to ask?

                Like

  3. Hello,

    Thank you for this article. I’m a WomenHeart Champion, and it just strikes me when I read these types of misdiagnoses. A similar situation happened to my sister a few years ago.

    We have a very strong family history of heart disease. Our mom died at age 38 when I was only 15 years old, and in 2010, I underwent quintuple bypass surgery at age 49.

    On a Saturday morning my sister went to her doctor with all full symptoms of a heart attack, and even though the doctor knew of her family history, he told her that she was just stressed and needed to relax, and sent her home with a prescription to help her with stress (she was unemployed at the time and indeed was stressed) yet he overlooked the heart attack signs and sent her home.

    Being a WomenHeart Champion, and being aware of the importance to advocate for our own health, when my sister called me that day to tell me about her experience, I could not believe that he didn’t not send her to the ER. I told her that if she felt those symptoms again, to run for her life and immediately go to ER and insist that she needed to be treated for heart attack and consider the strong family history.

    The following morning, my sister almost passed out, and her daughter took her to ER. Indeed, the day prior, when she had gone to her doctor, she had undergone a heart attack. Now at the ER the following day, she was treated accordingly and had a procedure where she had 2 stents.

    A couple of years ago she started having similar symptoms, and this time, the cardiologist who treated her placed another stent, and told her that she had a very bad blockage which had not been treated and which was very difficult to repair (he was shocked that my sister had survived).

    Thank you for having posted your article, and for reading my response. This is a subject that feels very close at heart due to my life experience and battle with heart disease.

    PS: my son is now 32, and being aware of my family heart disease history, when he was 6 years old, I had him tested for cholesterol levels, and it was 350 at age 6.

    Regards,
    Yaskary Reyes

    Liked by 1 person

    1. Hello Yaskary – thanks so much for sharing your story (and your family’s dramatic stories, too). Your mother was tragically young when she died – such a sad loss for you as a teenager. With your own surgery at just 49 plus that kind of family history, it’s hard to believe that your sister was misdiagnosed with “stress” when she presented to Emergency with “full symptoms of a heart attack”.

      I often wonder when I hear of this kind of experience if that Emerg doc would have said the same thing to a male patient who presented with heart attack symptoms and a significant family history like you and your sister have. Somehow, I doubt it.

      One of the women in my Heart Smart Women presentation audiences told me of overhearing a conversation when she had recently been in Emergency, behind the curtain separating her bed from the one next to her. The Emerg doctor said to the (male) patient next door: “All of your cardiac tests came back ‘normal’, but we’re going to admit you for observation just to make sure it is not your heart!”

      Why didn’t your sister hear exactly those words, too? Good luck to her – and to you.

      Take care, stay safe. . . ♥

      Like

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