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NOW THE WRONG QUESTION?
No one wants to make mistakes, least of all doctors whose mistakes may kill their patients. The classic paper by Wu et al1 which is republished here shocked the medical establishment in 1991 by revealing how many doctors in training (interns and residents) were aware of having made serious mistakes in their first few years of hospital practice. Some of these probably led to the death of patients. The causes of the mistakes were often multiple and included lack of knowledge or experience, failure of supervision, faulty or delayed decision making, job overload, and fatigue.
Has anything changed in the decade or more since that paper was published? The study recommended that the underlying causes of error should be addressed: inexperienced trainees should be actively supervised by their seniors (especially in complex cases) and job overload should be tackled. The lot of the junior doctor has certainly changed. In Europe there has been a reduction in junior doctors’ hours of working and these will be further reduced with the European Working Time Directive. In the USA the US Accreditation Council for Graduate Medical Education has limited the hours of work for junior doctors to 80 per week from July 2003. In the UK this is 56 hours by 2004, reducing further by 2009. Doctors are now transferring to shift systems for emergency on call work, thereby reducing the actual length of time on call. This may reduce error by reducing sleep deprivation but, against this, it may increase the frequency of handovers, a risky process unless well managed. There tends to be more supervision by seniors or other members of the multidisciplinary team, and more clearly defined roles and levels of responsibility—as has been identified by successive reports of the National Confidential Enquiry into Perioperative Deaths (CEPOD) in the UK.2 Doctors do not now work in isolation but as members of teams which are usually multiprofessional. In health care around the world there is a growing awareness of errors occurring, with an increase in efforts to assess their causes and improve patient safety. Although not universal, junior doctors are beginning to be taught to recognise when errors or “near misses” occur. They are learning what to do when they occur and how they may be prevented from happening again. Appraisal and assessments are recognised as an integral part of training and provide the opportunity to ensure that responsibility is tailored to the competence of the trainee.
In the paper by Wu et al,1 only half of the junior doctors who admitted to being responsible for an error told a senior colleague and a mere quarter told either the patient or the patient’s family. The doctor/patient relationship and the way that patients interact with the healthcare system has changed in the past decade. Previously, the culture of “the doctor knows best” predominated. Now doctors are encouraged to discuss diagnoses and treatments with patients and to empower the patient to take part in the decision making process. Patients are now better informed and are more likely to question their treatment and the outcomes—good or bad—with their doctor. If errors come to light, should the patient be told and do they want to be told? Whitman et al3 concluded that patients want to be told about adverse events even if minor, while Lo4 argued that patients need only be informed of major events. All patients are individuals and different. Patients are part of the system and therefore also have responsibilities.5 It no longer seems justifiable to keep patients in the dark about the risks and alternatives to interventions, nor about any adverse events or complications as they arise.
The young doctors in the study were willing to blame themselves for their mistakes, and most responded by promising to do things differently in future, and criticising or lecturing themselves. They changed their own personal practice by increased information seeking and increased vigilance. But medicine is complex and riddled with uncertainties. Medical error rates are unlikely to reduce as a result of individuals resolving to be more careful in the future. Lessons from aviation suggest that confidential “no blame” reporting is more effective in ensuring that lessons are learnt not just by the individual but by the organisation. Such a system has led to an increase in reported errors, but a decrease in their seriousness.6 In practice, are all medical errors reported? If the levels of errors from anonymous surveys are to be believed, then obviously not. Therefore what is stopping house officers from reporting their errors? Mostly it is a defence against being seen as a doctor who has made an error—a “bad” doctor—which may blight their careers, or to a more serious fear of being sued by the patient or being investigated by the General Medical Council and possibly even being suspended.
In the past the focus has been on blaming the individual who made the mistake. Doctors are now part of multiprofessional teams that work within an institutional environment. Institutional organisation has a large role to play as the error may be due to the system and not the individual. It is usually wrong to blame the individual as the system should make it easy for the right action and difficult for the wrong action to occur. The junior doctor may just be at the end of the line following a cascade of minor errors within the system leading to a major error. If so, the major error could have been prevented at any of the minor stages. The system and the individual cannot be viewed separately. Improvements in the system have to be matched by awareness in the individual. This has been recognised in other industries such as the airline and the nuclear industries. They have instituted risk assessment programmes to try and identify minor problems before they escalate into a major catastrophe. Barach and Small have shown how lessons learnt in these non-medical industries can be applied to the design of safety systems in health care.7 These lessons are now being adopted by the health service. St George’s Hospital in London has established a course to train staff to recognise the early indicators that may lead to an error.8 Risk management is a responsibility of all members of the team.
We are moving from a culture of “naming, blaming and shaming” to one of encouraging reporting and consequently improving the service. The individual, especially at house officer level, should not necessarily be seen as the guilty party, yet we still see cases where manslaughter charges are brought against individual junior doctors for errors that have unfortunately led to death. The mistake should be seen as one that got through the system—a system error, not an individual’s error alone. It is therefore the system that needs changing. The responsibility lies with both clinicians and managers to learn from the error, not just the individual.
The paper by Wu and colleagues asked whether house officers learnt from their mistakes. Now it sounds like the wrong question. What is the point of only individual junior doctors learning from their own mistakes? The organisation also needs to learn, to disseminate that learning, and to make sure the lessons are learnt not just for the present but also for the future. Doctors will continue to fail to report errors while there is a culture of blame. Instead, we need a culture—individually and institutionally—of identification and reporting of errors leading to correction, learning, and improvement in the provision of health care. We should not be asking whether house officers learn from their mistakes, but whether the health service learns from the mistakes that its systems allow to happen, and whether the system can be changed for the benefit of patients and those members of staff working within the organisation. Leadership is essential to making the changes happen and keeping the organisation focused.9,10 Education and training is the key to success, both at undergraduate and postgraduate levels. It has been shown that, if education and training is aimed at specific targets with good data, standardised tools and methods, then this leads to greater patient safety.11,12