I made a medical mistake I'll never forget

Early in my medical career, I made a mistake that I will never forget.

During my second year of residency, I was the senior overnight resident, which meant I was responsible for responding to hospital codes—even for patients not on our service. Late one night, a code blue was called; I quickly rushed into the room to help run the code. I didn’t know the patient, and the nurses were already performing CPR and giving meds.

We intubated and coded for 20 minutes before I called time of death. This was devastating in itself, but when I called to notify the patient's physician (an oncologist) about the death, I was in for another shock. He told me this was an end-stage cancer patient with a do-not-resuscitate (DNR) order.

I was mortified, especially because I am a huge advocate for discussing and respecting code status with each one of my patients.

Owning up to it

There was no sign of code status on the patient’s door or in his room, but when I flipped to the back of the chart, it was right in front of me. I spoke with his nurse and the nurse manager and asked if anyone was aware of his code status; the answer was “no.”

I was angry and defensive. But as the physician on duty, I knew I would take responsibility. I'd have to communicate my actions with the family, regardless if the code was already called and in progress before I entered. So I contacted the patient’s wife, explained what happened, apologized, and told her she could come see her husband when she was ready.

What are the root triggers for medical errors?

Medical errors are common among the healthcare provider community and can be attributed to:

• Physician burnout or depression

• Miscommunication

• Not double-checking our work

• Clunky electronic medical records

• Simple human error

• And more

Many of these mistakes are committed by caring, conscientious providers.

Medical errors can range from a simple miscommunication about the name of a medication during a conversation between a physician and nurse to the incorrect programming of complex medical devices such as a ventilator.

Medical errors include wrong diagnoses due to mislabeled blood tubes, surgical errors due to inaccurate instrument counts and documentation, improper medication dosing because of faulty calculations, and a simple lack of communication as a patient gets passed from one provider to the next during change of shift.

A study published in Mayo Clinic Proceedings showed that physician burnout is at least as responsible (if not more) for medical errors as unsafe medical workplace conditions.^[] Additionally, a study published in JAMA Network Open directly linked medical errors to physician depression.^[]

A good source of information on what causes medical mistakes is Dr. Danielle Ofri’s 2021 book, When We Do Harm. It explores the health care system flaws that foster errors, and is an excellent read for all healthcare providers.

Looking at the numbers

Research has shown that medical errors account for as many as 251,000 US deaths annually, making medical errors the country’s third-leading cause of death.^[] Medical errors in the US are significantly higher than in other developed countries such as Canada, Australia, New Zealand, Germany, and the United Kingdom.

These numbers do not account for the "near misses," in which a mistake was made, but the patient didn't suffer an adverse response.

This lack of transparency and accountability has been the norm rather than the exception in medicine. Many mistakes can be prevented, and there are appropriate steps to take after they occur.

Managing the aftermath

Although there are numerous systems and methods in place that can and should prevent medical errors, mistakes are inevitably going to happen. When you make one, consider taking the following actions to help rectify your error and review what happened so it’s not repeated.

• Acknowledge and accept that you made a medical error. Admitting your mistake honestly without placing blame on others is the first important step when a medical error occurs. Acknowledging the mistake is critical as it allows the medical team to investigate the error’s root causes.

• Review what happened and report the results to the family. It’s important to gather all of the information and discuss why an error occurred in an open, honest conversation with the patient and family. A review focuses on improving processes rather than assignment of blame.

• Avoid finger-pointing. It's so easy to blame others when we make a medical mistake. This only results in mistrust, poor communication, and grudges between medical staff, leading to more mistakes.For example, when I found out my patient was DNR, I initially wanted to blame the nurses for not knowing their patient’s code status and conducting a code before knowing it; however, this would have led to a stressful, unhealthy outcome for everyone involved.

• Engage, empathize, and apologize to the patient and family. Engaging with the patient and family not only leads to decreased medical-legal outcomes but also helps solidify the physician-patient foundation. We must be honest, empathetic, and humble when discussing our medical errors with a patient and their loved ones. Apologize to the patient or family, truthfully explain what happened, and describe what changes are being made so mistakes don't reoccur. These are significant steps that can be therapeutic for both physician and patient.