04 Sep MEDICAL ERROR – HOW TO DEAL WITH IT?
The article below, Medical error, co-authored by DVM Natalia Strokowska, was first published in the Polish Veterinary Magazine in August 2016. It covers dealing with one’s medical error, controlling emotions and communicating effectively with the owner about the situation.
“Every doctor has his own cemetery.” This powerful statement is true in human and veterinary medicine as well. We each make mistakes in our medical practice. Medicine is unpredictable, and, despite our best efforts, things do not always go well. Working under time pressure and stress
increases the chance of making mistakes. Sometimes we just have a bad day, or other problems distract us. What can we do when we make a mistake? How should we admit it? How could we talk to the customer? Our communication skills determine future customer relations.
Deep breaths and coolheaded analysis
First of all, breathe. Strong emotions hinder us from focusing on the client. Relax, and then move to a deeper level of concentration. It’s alright to say your feelings out loud, but the situation is not about you, it’s about treating the patient. The use of relaxation and controlled breathing techniques allows you to cope with excessive stress. It calms your racing pulse and heart palpitations. Your breathing should become regular and balanced. Breathe in through your nose and breathe out through your mouth. Inhalation and exhalation should be equally long. No matter if you’re sitting or standing. Straighten up, lift your chin if it feels right, and lay your hands on the solar plexus. Feel the movement of your diaphragm. It is important to breathe from your diaphragm. This comes more natural for men than for women, so as a woman, remember the deep, “from the stomach” inhalation you use when singing. Do you practice yoga? Then the pranayama breathing will help you a lot.
Mastering the techniques of irritation, sadness and anger management can grant us a more professional approach. Openly talking about emotions is acceptable as long as the client stays in the focus of attention. It is important not to postpone talking to the customer about the error, and keep them informed. Often, attempting to hide a mistake is much worse than the mistake itself. With time, admitting the mistake gets more and more difficult.
Only a few clinics have protocols that explain the desired proceedings. Should the veterinarian discuss the error with the employer first? Should they act based on the relevant literature in complicated situations like shock or poisoning? It is sure that having an algorithm for specific difficult
cases reduces the chance of making a mistake. It is worth practising how to have a calm, factual conversation with the client, by thinking through alone or with colleagues.
Set the environment, address the issue, explain the situation
Invite the client to the office. Ask them to sit, and seat yourself as well – so that they feel you are on the same level. Be calm, remember the words you designed beforehand. Be aware of your body language: maintain an open posture (do not cross your arms), look at the client and keep the eye contact. Sometimes you have to inform the client about an error on the phone, which eliminates non-verbal communication techniques that could help.
Start off by saying the subject of the conversation is serious. This will help the client prepare for receiving difficult news and to get themselves ready to listen to it. Ask whether you can start – this gives the client a sense of control over the situation. Continue or wait until a third party (e.g. a second owner or another employee of the clinic) joins. “Ma’am, I would like to talk to you about Tosia. First of all, I want to assure you that everything is OK with her. Unfortunately today, during the sterilization, I made a mistake that might worry you. Is it the right time for you to talk about what happened?”
Tell them the events slowly, chronologically and logically. This will allow the customer to process the information. “Tosia was prepared and anaesthetized. We removed her uterus and ovaries through a small incision in the middle of the abdomen. The blood vessels and the stump of the uterus and the ovary vessels were tied up. We sutured the abdomen. After the surgery, Tosia was transferred to a hospital. There, under the control of a veterinary technician, she was waken up. Unfortunately, she started to feel worse and worse within a few hours. We suspected that there was a bleeding in the abdominal cavity, and we decided to reopen her abdomen in order to stop it. During the procedure, we found that the patch slipped off the ovary. We stopped the bleeding and placed a double patch. We removed the blood from the abdominal cavity, and sutured Tosia’s belly again. Currently we have
her on IV, here in the hospital, because she’s lost some blood. She will have to stay here for two more days. She’s feeling better now, so you can visit her. Naturally, we will cover the additional costs of the second surgery.”
Apologize and tell the truth
An apology is a crucial part of explaining a medical error. Taking responsibility for our mistake helps rebuild the relationship with our customer. If someone from the veterinary clinic made a mistake, the team member and the supervisor should apologize together. “I am very sorry this situation happened. I am very sorry that, because of me, Tosia had to go through an additional treatment and for the stress it caused you.”
By asking questions, we can check whether the client understands and follows us. “I know that these are disturbing news for you. Do you have any questions? Can I continue?” Keep your balance and distance. Don’t give the impression that you are expecting answers. Have a good speech prepared
before the conversation.
Be honest, empathetic and understanding. Answer questions confidently and accurately. Do not conceal any information. If you avoid to answer or stay silent, the client is more likely to question you and make accusations. If they hear a true, compassionate and caring statement, their emotional
trauma is lighter. Then, it is less likely that a claim for medical error or financial compensation occurs. Also, most importantly, the client will want to continue treating their pet in your clinic.
Have no expectations and be open to learn a lesson
You and your customer both struggle with strong emotions. You might feel fear not knowing the owner’s reaction. Unfortunately, there is no way to predict it. The only thing you can do is stay flexible. Don’t set yourself up for one scenario. This will help you respond even in the most stressful moments. “I understand your disappointment. I understand how disturbing this information is for you.”
Lastly, you need to discuss the further treatment of the animal. Stress that this situation will never happen again. Make a plan in order to eliminate future errors, and implement it. “I know that nothing can change what happened. However, with my colleagues, we have created a new error identification protocol that we are implementing immediately. I also would like to discuss what is important for you and Tosia, in relation to the mistake I made.”
Flow of information and medical records
Before each surgery or medical procedure, we should inform our customer about what exactly we are going to do, about potential complications and what they should prepare for. This will make it easier to talk later, in case you make any mistakes. The client should be given the written description
of the procedure and the risks that it entails, along with a declaration to sign. It is important to emphasize the importance of additional tests (e.g. blood tests, ultrasound, X-ray), which provide us with information on the animal’s health and allow us to determine the likelihood of risks. You should prepare corresponding forms for specific procedures. If the client refuses to carry out additional examinations, it should be marked in medical records. This will let us claim that the diagnostic process was limited, which could lead to incorrect diagnosis. It is well worth following the protocol of the given workplace. You can seek advice from a legal advisor, your employer or your colleagues.
Medical error management schemes
The CONES protocol (C – context, O – opening shot, N – narrative approach, E- emotions, S – strategy and summary) draws attention to several important elements of coping with medical error. It advises us to, while preparing for a conversation, pay attention to the physical context, the correct start of the conversation, the adequate narration, the emotions involved in the situation and the strategy you can use.
Planning the physical context of the conversation is essential. The conversation needs to be conducted in the right place. It is beneficial to invite the client to a private room and offer them a place to sit and a drink. If possible, have the conversation face to face. A telephone conversation
does not allow you to use body language, which can play a key role in the conversation.
Start the conversation by indicating that the topic is heavy, to prepare the client to receive the information. Then, explain how the mistake occurred, and why it happened. Speak slowly. Ensure the client that you are at their disposal. Answer all their questions. It is important to communicate complete and true messages. Clients who received information this way and had direct contact with the doctor who made the mistake were 50% less likely to take the case to court.
Apologizing is a key moment of talking about a medical error. Only by admitting the mistake and showing regret can we rebuild trust between the client and the doctor. It is important to show empathy towards the customer by using phrases such as “I understand that you are upset…” and “I
am aware of your disappointment…“
End the conversation by emphasizing that in the future you will do everything to avoid such errors. Tell the customer what steps you are going to take and how you are going to develop your procedures to prevent such situations.
Medical error and stress
Committing a medical error always induces stress – this phenomenon is called Medical Malpractice Stress Syndrome (MMSS). MMSS does not only affect the doctors themselves but their families, co-workers and clients as well. They experience a feeling of deep shame, frustration, anger and often depression. When experiencing these symptoms, it is worth seeking the help of psychologists or psychiatrists. To avoid MMSS, medical professionals should find time for hobbies, physical activity, healthy eating, family and relatives. This will allow us to back away from the matters for a short period of time. It is also a good idea to analyze our career and realize that we have successes behind us, despite our stumble. When a case is taken to court, and the client wants to see legal consequences, it is important to actively participate in the process. This can give us a sense of control and moderate the stress.
As veterinarians, we should avoid situations where we are afraid of committing a mistake. Not feeling self-assured can have a negative effect on our work. When we experience stress due to medical error, it can help to reach out for opinions and consultation from other veterinarians, as well
as words of support which we can find, for example, on professional forums or in Facebook groups. As a consequence, it becomes easier to avoid mistakes, our stress level decreases, and we can act more confidently and correctly. In difficult cases, consulting the problem with other professionals and brainstorming can be advantageous. Do not feel embarrassed when receiving help form colleagues. We can learn the most and come up with constructive conclusions when we exchange our experiences and know-how. Asking other veterinarians’ advice for a diagnosis does not show our weakness but our commitment and professionalism.
Even if the diagnosis seems obvious to us, it is worth taking the time to generate differential diagnosis. In medicine, there are two diagnostic methods: pattern recognition, which requires a lot of experience and many previous cases, and differential diagnosis, which allows to determine the most probable causes of the problem. It involves an in-depth analysis of history, disease history, course, description of the animal, symptoms, clinical examination and results of additional examinations.
We can use the mnemonics VITAMIN D in differential diagnosis to check the possible causes in each disease group: V – vascular, I – infectious, T – trauma, A – anomalous, M – metabolic, I – immune-mediated/inflammatory, N – neoplastic, D – drug/toxic. The thorough analysis lets us consider the possible causes of symptoms in each groups in a structured way, and choose the most probable one for the given case. This way, it is easier to make an accurate diagnosis and avoid mistakes.
Even if everything seems to be ok – do the tests
Dr. Aubrey J. Lavizzo, the owner of The Center for Animal Wellness in Denver, Colorado mentioned the most important learning experience of his practice in a short interview for the Veterinary Team Brief. He said, it doesn’t matter if he made a mistake a few days ago or a few decades ago – every lesson is valuable, and conclusions need to be drawn from it.
One day he was visited by a lively Scottish terrier. The owner said he had been unwilling to eat for a few days. The examination showed that the dog was in perfect condition, so he sent him home without any comments, tips or control plan. The next day the patient went to another doctor, who
found that the dog had intestinal obstruction as a result of swallowing a corn cob. Dr. Lavizzo determined three learning points based on this failure: 1.A thorough examination should be carried out each time, even if the problem is easy to identify. 2.ALWAYS confirm the condition of the animal by phone or at an inspection visit, especially if you do not have a clear answer or are not able to dispel the owner’s doubts. 3. Listen actively to each client. They always know more about the animal than we do (or at least most of them).
We should learn from each mistake, and take actions to minimize the risk of them happening again. Our communication with the customer (sincere, objective, compassionate, calm and empathetic) determines the further relationship with the customer. The key to success is conscious breathing,
mastering stress and emotion control, professional conversation in the right time and place (not delayed for later), being open to the customer’s needs, assuring them about our best intentions and sincerely apologizing.
Authors: DVM Natalia Strokowska, DVM Anna Didkowska