The emotional resistance to admitting error cannot be legislated away

It’s been more than a decade since the seminal report “To Err is Human” by the Institute of Medicine.  The report made waves when it estimated that 1.5 million people are affected by medical errors and that nearly 100,000 die annually as a result of medical errors. Some of those numbers have been debated, but there is no doubt that medical error is a significant issue in medicine that needs to be addressed.

Most errors are “systems errors,”—  flaws in the system, such as a different medications in similar-looking packages. These errors are usually easier to identify and simpler to fix. Certainly the electronic medical record is making strides in minimizing error due to illegible handwriting, drug interactions, misplaced paper records, etc.

Error due to the individuals is less common but in much harder to address. Computers and electronic medical records can help us, but they have their limitations.  The first step in dealing with individual error is convincing healthcare workers to come forward and admit errors when they occur. This is one of the biggest challenges in the field of error prevention.

Obviously the fear of lawsuits is an enormous deterrent.  Most doctors — they are the ones who are sued the most — have a nearly reflexive fear of saying anything that might result in a malpractice suit. Increasingly, there is a recognition that we need legal protections for doctors who admit errors and apologize to patients, but that only addresses one part of the issue.

The emotional resistance to admitting error, the shame and guilt, are powerful barriers to owning up to error. These emotions cannot be legislated away. In a recent issue of Health Affairs, I write about a medical error I committed as a doctor-in-training. It has taken me nearly two decades to speak publicly about this because of how painful it was. However, speaking openly about our errors is the only way to teach the newer generation of doctors how to be honest about error.

Danielle Ofri is an internal medicine physician and author of What Doctors Feel: How Emotions Affect the Practice of Medicine.

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  • Louis Cornacchia

    Thank you for helping to bring humanity into the issue.
    Very nicely written.
    Louis Cornacchia, M.D.

  • Don Berry

    Read Dr. Orfi’s piece in Aug 2010 Health Affairs, 29:8, pg 1549 – 1551.

    As she relates in the piece:

    “The nurse took the order from me, while passing a bottle of saline to another medical resident. “Do you want to give an injection of long-acting insulin before stopping the insulin drip?” she asked me, as the clerk pressed two more charts in her direction.

    “I thought for a moment. Why would I want to use the sledgehammer of long-acting insulin after eight hours of our meticulous adjustments with the insulin drip? “No,” I said, turning to my intern capitalizing on the teaching moment. “If we push him overboard with long-acting insulin, it’ll be stuck in his system for hours, and his sugar could bottom out. Let’s just keep checkinghis gluocose hourly and givef him short-acxting insulin as needed.”

    “The nurse raised her eyebrows ever so slightly”.

    “The intern nodded with me — my logic was obvious. The nurse shrugged and went back to her work.”

    Now … if you are a second year resident only two weeks out of your internship … and a nurse raises her eyebrows at something you say to an intern in your “I’m a doctor” tone.

    Suggest you go back and look up what you just think you know in a book before you kill somebody. Dr. Ofri didn’t check … and almost killed her patient.

    That’s what all of her guilt and shame is tied to. Her error in her residency when she forgot something basic … and even more alarming … wasn’t paying attention to the nurse who probably had more than 2 weeks as a professional under her belt.

  • BobBapaso

    The fear of lawsuits cannot be legislated away either, unless a system is created where there are no lawsuits. If those who suffered injury were compensated fairly and quickly there would be little resistance to admitting errors and apologizing. This would go a long way toward preventing errors. If it was the thing to do there would be less guilt or shame about it.