“Mistakes are a Fact of Life” – This Includes Medical Errors
Poet Nikki Giovanni said “Mistakes are a fact of life. It is the response to error that counts.” Eleanor Roosevelt advised people to “learn from the mistakes of others. You can’t live long enough to make them all yourself.” Both of these women make clear that mistakes are a part of life. What’s important is whether we turn mistakes into opportunities to learn and grow.
In order to do so, we need to admit that we’ve made a mistake, examine why it happened, and figure out what we need to do to ensure that we don’t make the same error again. Unfortunately, in health care, providers rarely take this approach.
The Prevalence of the Medical “Near Miss”
Dr. Danielle Ofri, an internist at Bellevue Hospital in New York City, recently published When We Do Harm: A Doctor Confronts Medical Error. In a recent interview with NPR, Ofri contends that “the reporting or errors is key to improving the system.” She explains that currently, doctors do not report “near misses” – those incidents when a mistake is made that has no serious negative impact on the patient.
Though these situations could provide valuable information that would lead to the prevention of similar mistakes in the future, “shame and guilt” cause doctors to remain silent. What’s even more concerning is the potential negative impact that remaining silent about making a mistake has on doctors and patients. Ofri confesses that due the distress she felt after a near miss situation, she is “sure [she] harmed more patients because of it.”
The Case for Reporting “Near Misses”
Ofri makes a compelling argument for reporting near misses. "Near misses are the huge iceberg below the surface where all the future errors are occurring," she says. "But we don't know where they are ... so we don't know where to send our resources to fix them or make it less likely to happen." Unreported errors mean that healthcare providers cannot review why they happened and make changes in order to prevent them from continuing to happen.
Some Changes to Consider
Ofri suggests the following ways to change the culture and minimize errors:
- Think ahead to anticipate problems and develop ways to avoid them
- Use a checklist that helps healthcare providers pay attention to the steps in the process
- Recognize that electronic records are designed to focus on billing, not patient care
- Encourage patients to “be vigilant” by keeping track of what’s happening, asking about medications, and knowing their rights
The most effective way to minimize errors is to report them. Pennsylvania requires that all “events of harm or potential for harm” be reported. While the rates of reported incidents increased – Pennsylvania has the largest event reporting database in existence – the reporting led improvements in patient safety culture, which in turn led to reduced harm to patients.
Even the most competent, caring health care provider will make mistakes. But the current practice and culture that does not require “near misses” -- those mistakes that do not have an adverse effect on patients -- to be reported prevents doctors from using their experiences to improve systems and provide better care for patients. As a result, today’s “near miss” very likely will become tomorrow’s “actual injury.”
If you or someone you love has suffered as a result of a medical error, call our experienced Cleveland malpractice lawyers to discuss your options for legal recourse and for obtaining the compensation you deserve. To schedule your free consultation, call 216-287-0900 or contact us online today.