First do no harm – but to err is human

During my hospital-based training, a senior clinician advised me that it would be unlikely that I would go through my medical career without receiving any complaints about my work.  He was right. 

As health professionals we tread the line between doing no harm and keeping patients safe, while being human and therefore not omnipotent.   Fortunately for me, none of the complaints I received turned into formal notifications from the doctors’ registration body (the General Medical Council in the UK/the Medical Board in Australia). In nearly forty years of clinical practice, I can remember a few times when a patient or carer wrote to either my consultant (in hospital) or the practice manager (in general practice) about me.  Two were clinical mistakes I had made (luckily without serious consequences) and two were about communication. I also remember a GP colleague remonstrating with me about failing to provide an adequate follow-up plan for a patient with drug dependency when I was on leave, which she was quite right to do.   Complaints are distressing and lead to soul-searching and sometimes self-blame.  It is important to consider the patient’s perspective and learn from the episodes.  I certainly changed my practice as a result.   

However, I have made more mistakes than this without feedback.  And I have chastised myself on occasions when I haven’t performed as well as I would have liked but not strictly made a mistake. Without external feedback it can be difficult to evaluate one’s own practice – whether it is good or bad, which is why case discussions with colleagues are helpful but less likely when work is pressurised. 

I have noticed that across the media there is an increasing number of stories about health professionals’ errors, particularly of the type that focus on missed or delayed diagnoses by GPs or in emergency departments.  There is never enough detail to know what exactly was happening when patients with sepsis or other life-threatening conditions are advised to rest at home.  I am sure other doctors are reading these and thinking ‘what would I have done?’  Reading about medical mismanagement can be overwhelming. An uncertain GP might then refer patients with undiagnosed symptoms, say tiredness or cough, for investigations and specialist review, which would clog up the system and lead to longer waiting times.  

Health professionals are human and do make mistakes.  These may have long lasting consequences for patients.  We make incorrect diagnoses, mix up patients, prescribe the wrong medicine or the right medicine at the wrong dosage, mess up surgery, give incorrect advice and, when aware of mistakes, don’t make the effort to correct them.  

One definition of a medical error is ‘the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim’.  There is a whole area of research that looks at how mistakes are made and ways to prevent them.  In addition, when an error occurs, also known as a serious adverse event, there is a mechanism in hospitals and most general practices to review what happened and learn from the situation. Near misses are also likely to be investigated. 

If we think of the number of patient-health professional interactions that occur each day in a national health system, the number of serious mistakes is relatively small compared to the proportion of care that is good or excellent.  However, the number is rising in many jurisdictions. Most health professionals aspire to providing the best care possible and for patients to have optimal outcomes. 

Why do mistakes happen?  There are many and diverse reasons.  Some are the consequence of a series of small mistakes or oversights, involving many people, that lead to one massive error.  This chain of events may be a systems failure rather than a mistake that is caused by an individual.  An important systems factor is poor communication between health professionals particularly when care is transferred from one team to another, or one location to another.

Individual factors that lead to mistakes include lack of knowledge or skill, faulty diagnostic (clinical) reasoning such as jumping to the wrong diagnosis too soon, wrong medication, poor clinical judgment and tiredness, burnout and ill-health. 

If an error is thought to be due to an individual, and a formal complaint is made, the law aims to decide if there has been negligent practice.  For example was the health professional outside the standard of medical practice as accepted by current medical opinion.  In other words, if I do something which has an adverse outcome for the patient, but which was in accordance with what other doctors would do in the same circumstances, then I have not been negligent. This is the principle of the Bolam test introduced in England in 1957 which states that the law imposes a duty of care between a doctor and his patient but that the standard of care is defined by medical judgement (in the words of the day ‘a practice accepted as proper by a responsible body of medical men [sic] skilled in that particular art…’) This is not saying that the whole medical profession must agree as there are certainly differences of opinion as regards the management of many conditions, as medical knowledge is updated. In the last few decades, while the Bolam test is still applied in England, it has been recognised that it is of limited use in many medical cases that concern advice, consent or diagnosis,[1] as the case of James Bolam was about treatment.  In Australia the Bolam test has been modified.  Deciding what is negligent is not easy from the legal language used. 

Patients or families may complain because of a lack of communication. You can see the theme here that good communication is key to good healthcare practice.  Something bad happens to yourself or a loved one and you don’t understand the circumstances.  Research has shown that doctors may provide little information after a medical mistake or poor outcome.   Patients complaining may compel the sharing of information to try to understand what went wrong.   They may also want an apology and to reduce the risk of a similar mistake happening to someone else. 

It is hard to admit to mistakes and, historically, doctors were advised not to apologise as this would suggest negligence, and they would risk litigation. I don’t remember any such advice as a student.  I don’t remember any teaching about mistakes.  Medical schools do now include communication skills sessions on open disclosure and how to apologise, and courses on medico-legal issues.  Open disclosure is the open discussion with a patient/consumer/family about an adverse event that has resulted in harm.  It should include a review of what has happened and why, space for the patient to give their perspective, and an explanation of what is being done because of the incident including how to prevent something similar happening in future.  


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