My worst mistake was doing the wrong hand surgery procedure. I released the carpal tunnel when I was supposed to release a trigger finger. When I realized my error it was like the ground fell away from beneath me. As if my breath was taken from me. Dr. Brian Goldman captures the devastating shame: Not "I made a mistake", but "I am a mistake."
It was little consolation that other than an unnecessary incision on the palm, there was no lasting harm for my patient. My good fortune was that I work in a place that has worked steadily to move from the "blame and shame" culture of traditional medicine to the culture of safety successfully developed in aviation and manufacturing: Humans err and by anticipating errors we can limit them and catch them before they cause harm.
While leaving the operating room that day after completing the correct procedure, I saw the director of the operating room walking towards me. What would he say? The possibilities raced across my mind: "This is not acceptable"; "How could you let this happen?"; "Your operating privileges are suspended".
Wordlessly we walked into an empty operating room and he said, "How are you doing?"
He cared about me.
It was understood that I'm skilled. That I would do anything and everything to help my patients. That I would give my all to avoid harming them. That no one will be as hard on me as myself.
He wanted to make sure that I was OK.
He expressed his own regrets: "Just one more month. We're just about to roll out the new universal protocol with checklists and a time out procedure that would have prevented this." He focused on the systems that we develop to help good health care providers catch their errors before they lead to harm.
After a restless night, I looked forward to seeing patients in the office. For many of us, getting back to the meaningful work we love is part of the healing process. Getting back into the routine helps convince us that things will be OK in our darkest hour.
I was a bit late getting to the lunchtime meeting. About 20 people including the quality and patient safety team and all the staff involved in the incident were gathered and discussing what went wrong. When they invited me to speak I tearfully apologized: "I blew it. I'm so sorry I put all of you through this." That was about all I could get out. The Vice President for Quality and Safety (an MD raised in the Air Force) answered me with:
"I blew it."
"We blew it."
The message was clear. My accountability was appreciated, but because humans are imperfect, the key is effective safety systems.
I knew that sharing my story would help other patients and providers. The support of my team bolstered my courage and we presented my error as a case conference that was eventually published in the New England Journal of Medicine. When you give a story you get many in return. I've had many letters, emails, and conversations with people that wanted to talk about their error and thank me for risking my reputation; for doing my small part to help improve the culture. I thanked them for sharing their stories with me, because the camaraderie helped me heal. It helped me feel as if I had helped make it easier to discuss errors.
After the publication, I went on the "wrong procedure world tour" having been invited to speak in many forums, often in places where they are struggling to get to the kind of safety culture I'm fortunate to practice in. I pondered the best format for a talk. Do I talk about checklists? Do I show them data? Do I focus on policies? I came to the same conclusion Dr. Goldman did. The best thing to do is simply to tell my story.
I entitled the talk: "About my error". It starts: "We're going to do something unusual today. We're going to talk about my error... "
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