Mistakes you have made
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Mistakes you have made
Discuss what's in the BMJ and on bmj.com
A few years ago the National Patient Safety Agency published a mini booklet called 'Medical Error'. It had very senior Doctors describing 'in general terms' mistakes they had made as junior Doctors a
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Re: Mistakes you have made
posted at 26/5/2012 2:41 PM BST
on bmj.com
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Posts: 2947
First: 10/3/2009 Last: 29/4/2013 |
In Response to Re: Mistakes you have made: In Response to Re: Mistakes you have made : Hi Odysseus, you are a Doctor clearly with great experience and competence. In your career, perhaps in the early years did you ever make a judgement and later thought I should not have done that or I really should have done that? Posted by kirked No I cannot recall any catastrophic events I have caused but can remember some balls that would have gone through to the boundary had I not caught them. That is not to say I have not made errors We all do. it is the bad ones we remember. When I studied for my exams I used to think that if I got 80% right I was missing 20% and these were things which would affect my patients and their lives. I strove always for 100% and maintained this all through my undergraduate career and beyond. Few of us get 100% right (I did not) but I raised the bar for myself and apply this to all I do, be it Greek, French writing, fencing or sailing or even being a human being of substance. I compete with myself not others. I yet tread warily, sail safely and true to do my best to be competent and dependable. To me a catastrophic error is a nightmare I wish to avoid. None of us are above this. Attitude and perhaps luck are in this equation.
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Re: Mistakes you have made
posted at 26/5/2012 4:11 PM BST
on bmj.com
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Posts: 958
First: 15/7/2011 Last: 15/5/2013 |
Fair point. I agree that attitude and good communication with patients and colleagues can make a world of difference. As I said earlier I don't believe any Doctor sets out to cause harm and when mistakes are made most Doctors genuinely feel very bad about it. When I deal with Doctors in court perhaps because of a negligence case I try my best to get the message across that despite this case it does not mean you are a bad Doctor, you made a mistake just as every professional person does from time to time. Once the case is over you will get over it and continue to practise to the high standards you have always maintained. |
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Re: Mistakes you have made
posted at 26/5/2012 5:30 PM BST
on bmj.com
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Posts: 1280
First: 9/12/2011 Last: 14/5/2013 |
OK, here goes, Well one morning, on a day off I had just worked a double shift, and was going to get Gas for my car, and I was extremely tired, So I took a sip of coffee from my coffee cup, the coffee was cold, and not too tasty so I went to spit the whole mouth full of coffee out the window of my car, whilst driving 30 miles per hour, Except I forgot one key fact, THE WINDOW WAS CLOSED! So I got a face full of coffee splatter! The lady driving in the opposite lane of traffic was laughing so hard she almost ran off the road, I laughed too, It was funny! Enjoy People.... DuaneF |
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Re: Mistakes you have made
posted at 26/5/2012 8:20 PM BST
on bmj.com
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Posts: 958
First: 15/7/2011 Last: 15/5/2013 |
In Response to Re: Mistakes you have made: OK, here goes, Well one morning, on a day off I had just worked a double shift, and was going to get Gas for my car, and I was extremely tired, So I took a sip of coffee from my coffee cup, the coffee was cold, and not too tasty so I went to spit the whole mouth full of coffee out the window of my car, whilst driving 30 miles per hour, Except I forgot one key fact, THE WINDOW WAS CLOSED! So I got a face full of coffee splatter! The lady driving in the opposite lane of traffic was laughing so hard she almost ran off the road, I laughed too, It was funny! Enjoy People.... DuaneF Posted by DuaneF Duane, do you have an example of a mistake/error at work - it does not need to be catastrophic. |
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Re: Mistakes you have made
posted at 26/5/2012 11:33 PM BST
on bmj.com
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Posts: 2947
First: 10/3/2009 Last: 29/4/2013 |
Many mistakes occur from patients not following instructions. After explicit instructions and a handout on methotrexate one patient took it three times a day for a week. Another was given the wrong tablet size by a pharmacist and one patient passed blood from it for three weeks but did not ring me as he thought it would settle!. I tell patients the possible chain of events which can lead to the wrong dose being taken; doctor pharmacist, patient and even the dog. I tell patients to write the date they take it on a calendar and then on the day get someone to witness when they take it and sign in a diary that it happened. Sometimes the door bell rings the phone goes off and the patient is distracted while the dog then eats it off the kitchen table. If one is fastidious in one's methods and assume that the world conspires against one along with Murphy (Murphy's Law) errors are less the result of entropy and chaos theory. I once went to put a chest tube in a patient who was not mine. I checked the name and examined the patient and looked at the chest radiograph. There were two patients with the same (or near identical) name in that ward. I always check dates of birth and name on the chest radiograph. I went back and puzzled having not been told about this name problem (we now have systems in place to cope with this). I reexamined the patient and checked the side. All was well. Sometimes my staff will pull the wrong chart and insert the wrong letter in a patient's chart. I had one patient where some diagnoses crept into his file due to another patient's letter. I had not checked full name and date of birth. I went through the whole file and amended it. It was my fault that I had not picked up their error. My first delivery of a baby was at a precipitate delivery where I caught the baby. The mother died half an hour later of a cerebral haemorrhage. I still have her funeral notice from the local paper. It was no one's fault. Bad things happen. P.S. I believe it is imprudent to discuss catastrophic errors one has made on a public forum. One's medical defence lawyers may take a dim view of this even if it happened in the distant past. It is better to keep skeletons in closets.
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Re: Mistakes you have made
posted at 26/5/2012 11:57 PM BST
on bmj.com
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Posts: 2034
First: 12/3/2010 Last: 17/5/2013 |
Title: RTFM/L (Please look up what RTFM stands for. 'L' stands for Label. I had just given a spinal anaesthetic, the patient had been catheterised, positioned on their side and we were ready to go into theatre. Time was short, the spinal had been difficult, and I realised that I had not given the prophylactic gentamicin that guidelines indicated. I rushed to the cupboard and found the drug Hmmmmm! Unusual! It was normally in snap-top ampoules, this was a rubber stoppered vial. No matter, it was the right colour, I even noted it was in date and I slammed in four mls. We disconnected monitoring and were about to go through the theatre door when the patient gasped, "Can't breath"! Wow! I thought. Total Spinal! Must be turning him soon after the spinal, stirred up the CSF into turbulence. I already had propofol on tap, for TCI sedation, and turned it up to a GA dose, my magnificent nurse had the tube to hand and it went in. Gosh, didn't we do well in the face of that unexpected complication! Then the trainee asked, "Why did you use gallamine, DrD?" For you will be way ahead of me. Yes, I had given a paralysing dose of a neuromuscular blocker, by mistake for the antibiotic. Operation over, and patient well in recovery, I apologised and explained why he had had a GA when he expected a spinal with sedation. He was calm. I saw him again the next day, explained and apologised again. "Thank you, doctor, thank you!," he said, "Thank you, for saving my life!" I felt about two feet tall. But he never complained! John |
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Re: Mistakes you have made
posted at 27/5/2012 6:29 AM BST
on bmj.com
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Posts: 958
First: 15/7/2011 Last: 15/5/2013 |
In Response to Re: Mistakes you have made: Many mistakes occur from patients not following instructions. After explicit instructions and a handout on methotrexate one patient took it three times a day for a week. Another was given the wrong tablet size by a pharmacist and one patient passed blood from it for three weeks but did not ring me as he thought it would settle!. I tell patients the possible chain of events which can lead to the wrong dose being taken; doctor pharmacist, patient and even the dog. I tell patients to write the date they take it on a calendar and then on the day get someone to witness when they take it and sign in a diary that it happened. Sometimes the door bell rings the phone goes off and the patient is distracted while the dog then eats it off the kitchen table. If one is fastidious in one's methods and assume that the world conspires against one along with Murphy (Murphy's Law) errors are less the result of entropy and chaos theory. I once went to put a chest tube in a patient who was not mine. I checked the name and examined the patient and looked at the chest radiograph. There were two patients with the same (or near identical) name in that ward. I always check dates of birth and name on the chest radiograph. I went back and puzzled having not been told about this name problem (we now have systems in place to cope with this). I reexamined the patient and checked the side. All was well. Sometimes my staff will pull the wrong chart and insert the wrong letter in a patient's chart. I had one patient where some diagnoses crept into his file due to another patient's letter. I had not checked full name and date of birth. I went through the whole file and amended it. It was my fault that I had not picked up their error. My first delivery of a baby was at a precipitate delivery where I caught the baby. The mother died half an hour later of a cerebral haemorrhage. I still have her funeral notice from the local paper. It was no one's fault. Bad things happen. P.S. I believe it is imprudent to discuss catastrophic errors one has made on a public forum. One's medical defence lawyers may take a dim view of this even if it happened in the distant past. It is better to keep skeletons in closets. Posted by Odysseus Odyyseus I am not asking for catastrophic errors. Secondly as a Lawyer I assure you that you have no worries at all if you describe a case in general terms. Theoretically your identity is not known on this site (although it would be easy in many cases to identify people in other ways from here). No defence organisation would object to any Doctor describing experiences in the past that they have learned from. Just look at my initial post of the people who told of some very significant errors in theifr past. I just wonder if Doctors are afraid to show that they do make mistakes on a public forum?). Lawyers are just the same. Keeping skeletons in the closet is exactly what modern practice is trying not to do so new Doctors can learn from them. Every one of us makes mistakes, it does not diminish us. |
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Re: Mistakes you have made
posted at 27/5/2012 6:34 AM BST
on bmj.com
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Posts: 958
First: 15/7/2011 Last: 15/5/2013 |
In Response to Re: Mistakes you have made: Title: RTFM/L (Please look up what RTFM stands for. 'L' stands for Label. I had just given a spinal anaesthetic, the patient had been catheterised, positioned on their side and we were ready to go into theatre. Time was short, the spinal had been difficult, and I realised that I had not given the prophylactic gentamicin that guidelines indicated. I rushed to the cupboard and found the drug Hmmmmm! Unusual! It was normally in snap-top ampoules, this was a rubber stoppered vial. No matter, it was the right colour, I even noted it was in date and I slammed in four mls. We disconnected monitoring and were about to go through the theatre door when the patient gasped, "Can't breath"! Wow! I thought. Total Spinal! Must be turning him soon after the spinal, stirred up the CSF into turbulence. I already had propofol on tap, for TCI sedation, and turned it up to a GA dose, my magnificent nurse had the tube to hand and it went in. Gosh, didn't we do well in the face of that unexpected complication! Then the trainee asked, "Why did you use gallamine, DrD?" For you will be way ahead of me. Yes, I had given a paralysing dose of a neuromuscular blocker, by mistake for the antibiotic. Operation over, and patient well in recovery, I apologised and explained why he had had a GA when he expected a spinal with sedation. He was calm. I saw him again the next day, explained and apologised again. "Thank you, doctor, thank you!," he said, "Thank you, for saving my life!" I felt about two feet tall. But he never complained! John Posted by John D Thanks John for a great example. A senior colleague of mine when I was starting out noted I always seemed to be in a hurry and getting a bit flustered. He quoted Napoleon: Order walks with weighty and measured strides, disorder is always in a hurry. A quote I found very helpful. |
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Re: Mistakes you have made
posted at 28/5/2012 4:06 AM BST
on bmj.com
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Posts: 2947
First: 10/3/2009 Last: 29/4/2013 |
The Romans summed it up well before Napoleon who had a lot of time on his hands for reflection on St Helena. Festinat lente. (Hasten slowly). The Greeks say, Σιγά, σιγά. (Slowly, slowly). In a crisis (even medcal), time slows down. A person well trained does things in slow motion with deliberate and considered steps while onlookers panic. I have encountered this phenomen repeatedly, nay even in a gale while sailing. It is the prevailing of inner peace and calm amidst the storm. If you have not felt it, aspire to it.
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Re: Mistakes you have made
posted at 28/5/2012 8:30 AM BST
on bmj.com
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Posts: 958
First: 15/7/2011 Last: 15/5/2013 |
In Response to Re: Mistakes you have made: The Romans summed it up well before Napoleon who had a lot of time on his hands for reflection on St Helena. Festinat lente. (Hasten slowly). The Greeks say, Σιγά, σιγά. (Slowly, slowly). In a crisis (even medcal), time slows down. A person well trained does things in slow motion with deliberate and considered steps while onlookers panic. I have encountered this phenomen repeatedly, nay even in a gale while sailing. It is the prevailing of inner peace and calm amidst the storm. If you have not felt it, aspire to it. Posted by Odysseus What was Napoleon doing at St Helena and why did he such time to reflect? I am no classicist! (I know its irrelevant to the discussuion but would appreciate the lesson). |
