Editing Medical error (section)

== Mitigation (after an error) ==
Mistakes can have a strongly negative emotional impact on the doctors who commit them.<ref name="pmid6690918">{{cite journal |vauthors=Hilfiker D |title=Facing our mistakes |journal=N. Engl. J. Med. |volume=310 |issue=2 |pages=118–22 |year=1984 |pmid=6690918 |doi=10.1056/NEJM198401123100211}}</ref><ref name="pmid1506949">{{cite journal |vauthors=Christensen JF, Levinson W, Dunn PM |title=The heart of darkness: the impact of perceived mistakes on physicians |journal=Journal of General Internal Medicine |volume=7 |issue=4 |pages=424–31 |year=1992 |pmid=1506949 |doi=10.1007/bf02599161|s2cid=415258 }}</ref><ref name="pmid10720336">{{cite journal |author=Wu AW |title=Medical error: the second victim : The doctor who makes the mistake needs help too |journal=BMJ |volume=320 |issue=7237 |pages=726–7 |year=2000 |pmid=10720336 |doi= 10.1136/bmj.320.7237.726|pmc=1117748}}</ref><ref name="Waterman">{{cite journal |vauthors=Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, Gallagher TH |title=The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada |journal=Joint Commission Journal on Quality and Patient Safety |volume=33 |issue= 2|pages=467–476 |year=2007 |pmid=17724943 |doi=10.1016/S1553-7250(07)33050-X }}</ref>

=== Recognizing that mistakes are not isolated events ===
Some physicians recognize that adverse outcomes from errors usually do not happen because of an isolated error and actually reflect system problems.<ref name="pmid2013929">{{cite journal |vauthors=Wu AW, Folkman S, McPhee SJ, Lo B |title=Do house officers learn from their mistakes? |journal=JAMA |volume=265 |issue=16 |pages=2089–94 |year=1991 |pmid=2013929 |doi=10.1001/jama.265.16.2089 }}</ref> This concept is often referred to as the [[Swiss Cheese Model]].<ref name="Dean B 2000 232‐237">{{cite journal|vauthors=Dean B, Barber N, Schachter M |title=What is a prescribing error?|journal=Qual Saf Health Care|date=Oct 2000|volume=9|issue=4|pages=232–237 |doi=10.1136/qhc.9.4.232 |pmid=11101708 |pmc=1743540}}</ref> This is the concept that there are layers of protection for clinicians and patients to prevent mistakes from occurring. Therefore, even if a doctor or nurse makes a small error (e.g. incorrect dose of drug written on a drug chart by doctor), this is picked up before it actually affects patient care (e.g. pharmacist checks the drug chart and rectifies the error).<ref name="Dean B 2000 232‐237" /> Such mechanisms include:
Practical alterations (e.g.-medications that cannot be given through IV, are fitted with tubing which means they cannot be linked to an IV even if a clinician makes a mistake and tries to),<ref name="Romero‐Perez 2012 1–9">{{cite journal|last1=Romero-Perez|first1=Raquel|first2=Philippa|last2=Hildick-Smith|title=Minimising Prescribing Errors in Paediatrics - Clinical Audit|journal=Scottish Universities Medical Journal|date=September 2012|volume=1|pages=14–1|url=http://sumj.dundee.ac.uk/data/uploads/epub-article/014-sumj.epub.pdf|access-date=June 22, 2016|archive-date=January 10, 2021|archive-url=https://web.archive.org/web/20210110100836/http://sumj.dundee.ac.uk/data/uploads/epub-article/014-sumj.epub.pdf|url-status=live}}</ref> systematic safety processes (e.g. all patients must have a Waterlow score assessment and falls assessment completed on admission),<ref name="Romero‐Perez 2012 1–9" /> and training programmes/continuing professional development courses<ref name="Romero‐Perez 2012 1–9" /> are measures that may be put in place.

There may be several breakdowns in processes to allow one adverse outcome.<ref name="pmid17015866">{{cite journal |last1=Gandhi |first1=Tejal K. |last2=Kachalia |first2=Allen |last3=Thomas |first3=Eric J. |last4=Puopolo |first4=Ann Louise |last5=Yoon |first5=Catherine |last6=Brennan |first6=Troyen A. |last7=Studdert |first7=David M. |title=Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims |journal=Annals of Internal Medicine |date=3 October 2006 |volume=145 |issue=7 |pages=488–96 |doi=10.7326/0003-4819-145-7-200610030-00006 |pmid=17015866 |s2cid=29006252 }}</ref> In addition, errors are more common when other demands compete for a physician's attention.<ref name="pmid9593791">{{cite journal |last1=Redelmeier |first1=Donald A. |last2=Tan |first2=Siew H. |last3=Booth |first3=Gillian L. |title=The Treatment of Unrelated Disorders in Patients with Chronic Medical Diseases |journal=New England Journal of Medicine |date=21 May 1998 |volume=338 |issue=21 |pages=1516–1520 |doi=10.1056/NEJM199805213382106 |pmid=9593791 |doi-access=free }}</ref><ref name="pmid2725617">{{cite journal |last1=Lurie |first1=Nicole |last2=Rank |first2=Brian |last3=Parenti |first3=Connie |last4=Woolley |first4=Tony |last5=Snoke |first5=William |title=How Do House Officers Spend Their Nights? |journal=New England Journal of Medicine |date=22 June 1989 |volume=320 |issue=25 |pages=1673–1677 |doi=10.1056/NEJM198906223202507 |pmid=2725617 }}</ref><ref name="pmid1275366">{{cite journal |vauthors=Lyle CB, Applegate WB, Citron DS, Williams OD |title=Practice habits in a group of eight internists |journal=Ann. Intern. Med. |volume=84 |issue=5 |pages=594–601 |year=1976 |pmid=1275366 |doi=10.7326/0003-4819-84-5-594}}</ref> However, placing too much blame on the system may not be constructive.<ref name="pmid2013929" />

=== Placing the practice of medicine in perspective ===
Essayists imply that the potential to make mistakes is part of what makes being a physician rewarding and without this potential the rewards of medical practice would be diminished. Laurence states that "Everybody dies, you and all of your patients. All relationships end. Would you want it any other way? [...] Don't take it personally".<ref name="isbn1-56053-603-9">{{cite book |author1=Thomas Laurence |chapter=What Do You Want?|title=Extreme Clinic -- An Outpatient Doctor's Guide to the Perfect 7 Minute Visit |publisher=Hanley & Belfus |location=Philadelphia |year=2004 |isbn=978-1-56053-603-1 |page=120}}</ref>
Seder states "[...] if I left medicine, I would mourn its loss as I've mourned the passage of my poetry. On a daily basis, it is both a privilege and a joy to have the trust of patients and their families and the camaraderie of peers. There is no challenge to make your blood race like that of a difficult case, no mind game as rigorous as the challenging differential diagnosis, and though the stakes are high, so are the rewards."<ref name="pmid16418416">{{cite journal |author=Seder D |title=Of poems and patients |journal=Ann. Intern. Med. |volume=144 |issue=2 |pages=142 |year=2006 |pmid=16418416 |doi=10.7326/0003-4819-144-2-200601170-00014|s2cid=2927435 }}</ref>

=== Disclosing mistakes ===
[[Forgiveness]], which is part of many cultural traditions, may be important in coping with medical mistakes.<ref name="pmid15681676">{{cite journal |last1=Berlinger |first1=N |last2=Wu |first2=AW |title=Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error |journal=Journal of Medical Ethics |date=1 February 2005 |volume=31 |issue=2 |pages=106–108 |doi=10.1136/jme.2003.005538 |pmid=15681676 |pmc=1734098 }}</ref> Among other healing processes, it can be accomplished through the use of communicative disclosure guidelines.<ref name="annegrethannawa.com">{{Cite web|title=Medical Error Disclosure Competence (MEDC) -- Prof. Dr. Annegret Hannawa|url=https://annegrethannawa.com/medc|access-date=2021-04-21|website=prof. annegret hannawa|language=en-US|archive-date=April 21, 2021|archive-url=https://web.archive.org/web/20210421143753/https://annegrethannawa.com/medc|url-status=live}}</ref>

==== To oneself ====
Inability to forgive oneself may create a cycle of distress and increased likelihood of a future error.<ref name="pmid16954486">{{cite journal |last1=West |first1=Colin P. |last2=Huschka |first2=Mashele M. |last3=Novotny |first3=Paul J. |last4=Sloan |first4=Jeff A. |last5=Kolars |first5=Joseph C. |last6=Habermann |first6=Thomas M. |last7=Shanafelt |first7=Tait D. |title=Association of Perceived Medical Errors With Resident Distress and Empathy |journal=JAMA |date=6 September 2006 |volume=296 |issue=9 |pages=1071–8 |doi=10.1001/jama.296.9.1071 |pmid=16954486 |doi-access=free }}</ref>

However, Wu et al. suggest "...those who coped by accepting responsibility were more likely to make constructive changes in practice, but [also] to experience more emotional distress."<ref name="pmid8279153">{{cite journal |vauthors=Wu AW, Folkman S, McPhee SJ, Lo B |title=How house officers cope with their mistakes |journal=West. J. Med. |volume=159 |issue=5 |pages=565–9 |year=1993 |pmid=8279153 |pmc=1022346}}</ref> It may be helpful to consider the much larger number of patients who are not exposed to mistakes and are helped by medical care.<ref name="pmid16418416" />

==== To patients ====
Gallagher et al. state that patients want "information about what happened, why the error happened, how the error's consequences will be mitigated, and how recurrences will be prevented."<ref name="pmid12597752">{{cite journal |vauthors=Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W |title=Patients' and physicians' attitudes regarding the disclosure of medical errors |journal=JAMA |volume=289 |issue=8 |pages=1001–7 |year=2003 |pmid=12597752 |doi=10.1001/jama.289.8.1001|doi-access=free }}</ref> Interviews with patients and families reported in a 2003 book by Rosemary Gibson and Janardan Prasad Singh, put forward that those who have been harmed by medical errors face a "wall of silence" and "want an acknowledgement" of the harm.<ref>{{cite book |author1=Rosemary Gibson |author2=Janardan Prasad Singh |title=Wall of Silence |year=2003 |publisher=Regnery |isbn=978-0-89526-112-0 |url=https://archive.org/details/wallofsilenceunt00gibs }}</ref> With honesty, "healing can begin not just for the patients and their families but also the doctors, nurses and others involved." In a line of experimental investigations, [[Annegret Hannawa]] et al. developed evidence-based disclosure guidelines under the scientific "Medical Error Disclosure Competence (MEDC)" framework.<ref name="annegrethannawa.com"/><ref name="pmid9436897">{{cite journal |last1=Wu |first1=Albert W. |last2=Cavanaugh |first2=Thomas A. |last3=McPhee |first3=Stephen J. |last4=Lo |first4=Bernard |last5=Micco |first5=Guy P. |title=To tell the truth |journal=Journal of General Internal Medicine |date=December 1997 |volume=12 |issue=12 |pages=770–775 |doi=10.1046/j.1525-1497.1997.07163.x |pmid=9436897 |pmc=1497204 }}</ref>

A review of studies examining patients' views on investigations of medical harm found commonalities in their expectations of the process. For example, many wanted reviews to be transparent, trustworthy, and person-centred to meet their needs. People wanted to be meaningfully involved in the process and to be treated with respect and empathy. Justice-seekers wanted an honest account of what happened, the circumstances leading up to it, and measures to ensure it does not happen again. Processes that, for example, involved people independent of the organisation responsible for harm gave investigations credibility.<ref>{{Cite journal |last1=Shaw |first1=Liz |last2=Lawal |first2=Hassanat M. |last3=Briscoe |first3=Simon |last4=Garside |first4=Ruth |last5=Thompson Coon |first5=Jo |last6=Rogers |first6=Morwenna |last7=Melendez-Torres |first7=G. J. |date=2023-12-01 |title=Patient, carer and family experiences of seeking redress and reconciliation following a life-changing event: Systematic review of qualitative evidence |journal=Health Expectations |language=en |volume=26 |issue=6 |pages=2127–2150 |doi=10.1111/hex.13820 |issn=1369-6513 |pmc=10632635 |pmid=37452516}}</ref><ref>{{Cite journal |date=10 January 2024 |title=How to improve investigations of medical harm |url=https://evidence.nihr.ac.uk/alert/how-to-improve-investigations-of-medical-harm/ |journal=NIHR Evidence |doi=10.3310/nihrevidence_61101 |s2cid=266946352 |access-date=January 12, 2024 |archive-date=January 12, 2024 |archive-url=https://web.archive.org/web/20240112160213/https://evidence.nihr.ac.uk/alert/how-to-improve-investigations-of-medical-harm/ |url-status=live |url-access=subscription }}</ref>

A 2005 study by [[Wendy Levinson]] of the [[University of Toronto]] showed surgeons discussing medical errors used the word "error" or "mistake" in only 57 percent of disclosure conversations and offered a verbal apology only 47 percent of the time.<ref>{{cite web | last=Kelly | first=Karen | year=2005 | url=http://www.news.utoronto.ca/bin6/051117-1824.asp | title=Study explores how physicians communicate mistakes | publisher=University of Toronto | access-date=2006-03-17 |archive-url = https://web.archive.org/web/20060322154328/http://www.news.utoronto.ca/bin6/051117-1824.asp <!-- Bot retrieved archive --> |archive-date = 2006-03-22}}</ref>

Patient disclosure is important in the medical error process. The current standard of practice at many hospitals is to disclose errors to patients when they occur. In the past, it was a common fear that disclosure to the patient would incite a [[Medical malpractice|malpractice]] lawsuit. Many physicians would not explain that an error had taken place, causing a lack of trust toward the healthcare community. In 2007, 34 states passed legislation that precludes any information from a physician's apology for a medical error from being used in malpractice court (even a full admission of fault).<ref>{{Cite web |url=http://psnet.ahrq.gov/primer.aspx?primerID=2 |title=Archived copy |access-date=April 25, 2009 |archive-date=September 6, 2015 |archive-url=https://web.archive.org/web/20150906053931/http://psnet.ahrq.gov/primer.aspx?primerID=2 |url-status=live }}</ref> This encourages physicians to acknowledge and explain mistakes to patients, keeping an open line of communication.

The American Medical Association's Council on Ethical and Judicial Affairs states in its ethics code:
:"Situations occasionally occur in which a patient suffers significant [[medical complication]]s that may have resulted from the physician's mistake or judgment. In these situations, the physician is ethically required to inform the patient of all facts necessary to ensure understanding of what has occurred. Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with a patient."

From the American College of Physicians Ethics Manual:<ref name="pmid15809467">{{cite journal |vauthors=Snyder L, Leffler C |title=Ethics manual: fifth edition |journal=Ann Intern Med |volume=142 |issue=7 |pages=560–82 |year=2005 |pmid=15809467 |last3=Ethics Human Rights Committee |doi=10.7326/0003-4819-142-7-200504050-00014|s2cid=53090205 }}</ref>
:"In addition, physicians should disclose to patients information about procedural or judgment errors made in the course of care if such information is material to the patient's well-being. Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may."

However, "there appears to be a gap between physicians' attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation".<ref name="pmid17473944">{{cite journal |vauthors=Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE |title=Disclosing Medical Errors to Patients: Attitudes and Practices of Physicians and Trainees |journal=Journal of General Internal Medicine |volume=22 |issue=7 |pages=988–96 |year=2007 |pmid=17473944 |doi=10.1007/s11606-007-0227-z |pmc=2219725}}</ref> Hospital administrators may share these concerns.<ref name="pmid15769969">{{cite journal |vauthors=Weissman JS, Annas CL, Epstein AM, etal |title=Error reporting and disclosure systems: views from hospital leaders |journal=JAMA |volume=293 |issue=11 |pages=1359–66 |year=2005 |pmid=15769969 |doi=10.1001/jama.293.11.1359|doi-access=free }}</ref>

Consequently, in the [[United States]], many states have enacted laws excluding expressions of sympathy after accidents as proof of liability.

Disclosure may actually reduce malpractice payments.<ref name="pmid10610651">{{cite journal |vauthors=Wu AW |title=Handling hospital errors: is disclosure the best defense? |journal=Ann. Intern. Med. |volume=131 |issue=12 |pages=970–2 |year=1999 |pmid=10610651 |doi=10.7326/0003-4819-131-12-199912210-00012|s2cid=36889006 }}</ref><ref name="pmidWSJ">{{cite news |author=Zimmerman R |title=Doctors' New Tool To Fight Lawsuits: Saying 'I'm Sorry' |url=https://www.wsj.com/articles/SB108482777884713711 |work= The Wall Street Journal |page=A1 |date=May 18, 2004|archive-url=https://web.archive.org/web/20070823101409/http://www.mc.vanderbilt.edu/root/vumc.php?site=CPPA&doc=3270|archive-date=August 23, 2007}}</ref>

Reluctance to disclose medical errors to patients may also stem from [[psychological]] reasons. In his book, ''[[Medical Errors and Medical Narcissism]]'', John Banja defines "medical [[narcissism]]" as the need of health professionals to preserve their [[self-esteem]] leading to the compromise of error disclosure to patients.<ref>Banja, John, Medical Errors and Medical Narcissism, 2005</ref>

==== To non-physicians ====
In a study of physicians who reported having made a mistake, it was offered that disclosing to non-physician sources of support may reduce stress more than disclosing to physician colleagues.<ref name="pmid8601210">{{cite journal |author=Newman MC |title=The emotional impact of mistakes on family physicians |journal=Archives of Family Medicine |volume=5 |issue=2 |pages=71–5 |year=1996 |pmid=8601210 |doi=10.1001/archfami.5.2.71}}</ref> This may be due to the finding that of the physicians in the same study, when presented with a hypothetical scenario of a mistake made by another colleague, only 32% of them would have unconditionally offered support. It is possible that greater benefit occurs when spouses are physicians.<ref name="pmid10068390">{{cite journal |last1=Sobecks |first1=Nancy W. |last2=Justice |first2=AC |last3=Hinze |first3=S |last4=Chirayath |first4=HT |last5=Lasek |first5=RJ |last6=Chren |first6=MM |last7=Aucott |first7=J |last8=Juknialis |first8=B |last9=Fortinsky |first9=R |last10=Youngner |first10=S |last11=Landefeld |first11=CS |title=When Doctors Marry Doctors: A Survey Exploring the Professional and Family Lives of Young Physicians |journal=Annals of Internal Medicine |date=16 February 1999 |volume=130 |issue=4_Part_1 |pages=312–9 |doi=10.7326/0003-4819-130-4-199902160-00017 |pmid=10068390 }}</ref>

==== To other physicians ====
Discussing mistakes with other physicians is beneficial.<ref name="pmid2013929" /> However, medical providers may be less forgiving of one another.<ref name="pmid10068390" /> The reason is not clear, but one essayist has admonished, "Don't Take Too Much Joy in the Mistakes of Other Doctors."<ref name="isbn0-89815-197-X-b">{{cite book |author=Oscar London |chapter=Rule 35: Don't Take Too Much Joy in the Mistakes of Other Doctors |title=Kill as few patients as possible: and fifty-six other essays on how to be the world's best doctor |publisher=Ten Speed Press |location=Berkeley, Calif |year=1987 |isbn=978-0-89815-197-8 |chapter-url=https://archive.org/details/killasfewpatient00lond |url-access=registration |url=https://archive.org/details/killasfewpatient00lond }}</ref>

==== To the physician's institution ====
Disclosure of errors, especially "near misses", may be able to reduce subsequent errors in institutions that are capable of reviewing near misses.<ref name="pmid10720361">{{cite journal |last1=Barach |first1=P. |last2=Small |first2=SD |title=Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems |journal=BMJ |date=18 March 2000 |volume=320 |issue=7237 |pages=759–763 |doi=10.1136/bmj.320.7237.759 |pmid=10720361 |pmc=1117768 }}</ref> However, doctors report that institutions may not be supportive of the doctor.<ref name="pmid2013929" />

==== Use of rationalization to cover up medical errors ====
Based on anecdotal and survey evidence, Banja<ref name=banja1>{{cite book |last=Banja |first=John D. |title=Medical errors and medical narcissism |url=https://archive.org/details/medicalerrorsmed0000banj |url-access=registration |date=2005|location=Sudbury, Massachusetts |publisher=Jones and Bartlett |isbn=978-0-7637-8361-7 }}</ref> states that [[rationalization (making excuses)]] is very common among the medical profession to cover up medical errors.

==== By potential for harm to the patient ====
In a survey of more than 10,000 physicians in the United States, when asked the question, "Are there times when it's acceptable to cover up or avoid revealing a mistake if that mistake would not cause harm to the patient?", 19% answered ''yes'', 60% answered ''no'' and 21% answered ''it depends''. On the question, "Are there times when it is acceptable to cover up or avoid revealing a mistake if that mistake would potentially or likely harm the patient?", 2% answered ''yes'', 95% answered ''no'' and 3% answered ''it depends''.<ref>{{cite web |first1=Gail Garfinkel |last1=Weiss |date=January 4, 2011 |title='Some Worms Are Best Left in the Can' -- Should You Hide Medical Errors? |url=https://www.medscape.com/viewarticle/735033 |website=Medscape |access-date=September 8, 2019 |archive-date=March 1, 2021 |archive-url=https://web.archive.org/web/20210301034307/https://www.medscape.com/viewarticle/735033 |url-status=live }}</ref>

=== Legal procedure ===
{{Main|Medical malpractice}}

Standards and regulations for medical malpractice vary by country and jurisdiction within countries. Medical professionals may obtain [[professional liability insurance]]s to offset the risk and costs of lawsuits based on medical malpractice.