Regret, mistakes and speaking out

Many people have written about preventable mistakes and whistleblowing before, and many better than I at writing too. However, it’s not always discussed at medical school until just before students start work as junior doctors. Hopefully this somewhat poorly written blog might fill part of that gap for medical students.

I was in a lecture today on whistleblowing and challenging hierarchy today at the med school, as part of a mini-conference on patient safety and care quality for tomorrow’s doctors. The day was met with initial resistance by most, partly due to the perceived tediousness of the subject matter, but also because our finals are all in April and a whole day of irrelevant (to finals) talks seemed a waste. The previous mini-conference hadn’t been great either, so it was a pleasant surprise to find just how engaging and enjoyable the talks were. One of the most engaging speakers, who wrote the excellent book on A&E life In Stitches, spoke with tremendous passion on the subject of speaking out when you spot a mistake. Virtually everyone in the room, from student to consultant, raised a hand to when asked “who has witnessed a mistake but not said anything?”. Very few people had ever pointed out a mistake made by a senior (remember, for a medical student, EVERYONE in the hospital is a ‘senior’!). The doctor giving the talk had numerous personal stories (many also in the aforementioned book) showing how many errors are preventable. One example was of a medical student not putting their foot down and intervening when they noticed a surgeon was about to remove the wrong kidney from the patient in theatre. A completely preventable mistake.

So what should you do as a medical student if you aren’t comfortable with what’s happening in front of you? We’ll come to that, but first a short personal example of a situation which I deeply regret not voicing my concerns at the time.

I was in the busy A&E department of a teaching hospital (three guesses as to which one…) at about 3 am midweek (in my third year I tended to go in at night and the weekend to avoid the rush) with a student paramedic friend of mine (the best I’ve ever met, truly excellent). We were stood in A&E majors having a chat between returning to our respective patients who were both busy undergoing scans/clerking. There was a long queue of paramedics and ambulance technicians with patients on trolleys and in wheelchairs stretching from the nurses’ station out of the entrance. It was an unusually busy night for midweek, with most patients having excess alcohol as at least a complicating factor in their presentation. The medical team were working flat out.

Whilst we were catching up we noticed something in the queue of mostly GCS < 12 patients: there was a lady who was most definitely GCS 15, although she was gesturing oddly to the paramedic accompanying her. The paramedic tried to elicit the patient’s desire, but could make head nor tail of the stuttering gibberish that met the question “what’s up Mrs X?”. In the queue of intoxicated patients, this lady initially appeared to be just a little more conscious but nonetheless just as drunk as the others around her, however something about her appearance and gestures didn’t sit right with the usual A&E attender for EtOH XS. At the time, both the student paramedic and I volunteered on a very regular basis for St John Ambulance, and spent a great deal of our time observing or treating drunk patients. We knew how they acted and we knew how they sounded, and this lady didn’t quite fit. Unlike us, the paramedic had mist likely had many patients already that night whose indeterminable behaviour had been due to alcohol – they weren’t tuned in to notice this lady was clearly asking to go to the toilet, judging by her gestures, but was unable to voice her request, instead; stuttering and spouting gobbledegook.

At the time, I’d just completed a special study module in acquired brain injury and stroke, including all the weird and wonderful presenting symptoms, and my student paramedic friend had seen a long string of stroke cases recently. It was obvious to us what was wrong with this lady’s behaviour. She was aphasic – clear as day. Why hadn’t anyone noticed? Perhaps we were wrong, perhaps the paramedic knew but still had to queue. Perhaps the lady was going straight through to the medics just as soon as they’d checked in. We decided not to say anything. It was 3am, we were imposing ourselves on the already busy A&E staff and we had only glimpsed a situation that we weren’t really involved in whatsoever.

The very next morning, our care of the elderly lecturer was running a little late, and on arrival explained she had just been called to A&E to see a lady who had come in overnight. It had taken most of the night for anyone to realise that she had suffered a stroke, with the only determinable symptom being her aphasia. The physicians now had to play catch up to make up for lost time in diagnosing her condition. I was shocked. We had been right all along but never said anything. It might not have made a difference to the timing of her treatment given how busy the department was that night but who can say that for sure? I’ve never forgotten it.

So what should we have done? How should we have highlighted our concerns and to whom?

One method, particularly useful for students, is based on the PACEs system. Probe, Alert, Challenge and Emergency. The ‘probe’ stage is great for students who can gently ask “what is it you’re thinking here?” or something to that effect. If still uncomfortable with the situation, ‘alert’ allows further “are you sure?” and so on. Phrased in the right way, an unsure student can challenge an apparent mistake by a senior without having to worry about it reflecting badly. If needs be, based on the responses, a proper challenge (“I think this is a mistake”) can be appropriately facilitated.

A year later, on a busy infectious diseases ward round, the consultant and registrar were reviewing an X-Ray to decided whether a patient could stop taking antibiotics for a hospital-inquired pneumonia secondary to their initial, unrelated infection. The X-Ray was pretty clear, and they crossed off the antibiotics from the drug chart. However, the X-Ray they were viewing was of the wrong patient. The window they were viewing had been changed by another doctor whilst they were reviewing the patient and they hadn’t noticed. By asking “sorry, which patient is this X-Ray for?”, I was able to give them a pointer to check the name, without actually saying “you’re mistaken” – there was a chance of course that I hadn’t been paying attention and they’d moved on from the patient I thought they were discussing. This way, the mistake was noticed and corrected. The patient definitely needed to stay on antibiotics!

The rest of the lectures discussed other matters around patient safety. Having read all of Atul Gawande’s books (which everyone should do!), I’m glad the medical school put such a focus on this area of healthcare. I just wish I’d heard the lecturers sooner!

In summary, above all, regardless of whether it might create a scene or put you in a consultant’s bad books, speak up and speak out. You may just prevent a disaster.

UPDATE (25/1/13): Yesterday I was on a general medicine ward and noticed a patient from another firm sitting in her chair funnily. Quite an eccentric patient who often sits in odd poses and sings away to herself, I thought it’s probably ok. Although it had still made me stop and think “that looks odd”. Two minutes later her nurse noticed too and put out a stroke emergency call. Thankfully! Even though I’ve written above about speaking out, and even though there was nothing really stopping me in this case, it can be hard to say “hold on, something’s not right.” But we should. Just say something.

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6 comments

  1. john Wood · January 8, 2013

    This is a great blog which fits very nicely into the growing awareness of CRM in medicine and how it can safeguard patients – thanks

  2. fakethom · January 8, 2013

    I suppose it’s a type of fixation error on the part of the A&E and ambulance staff. Lots of drunk patients with similar behaviour. Reasonable to presume same when no other symptoms in this case to give more stroke clues.

  3. fakethom · January 22, 2013

    I’ve realised I don’t mean aphasia, rather dysphasia. Getting some words out but not the right ones.

  4. Luke McMenamin · January 25, 2013

    great post Thom… fantastic in fact. I’m using this in my teaching session tomorrow to the junior students.

    • fakethom · January 25, 2013

      Fantastic, thank you so much!

  5. Luke McMenamin · January 25, 2013

    it’s me @medicluke by the way!

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