A medical ombudsperson’s reminders on reducing errors in medicine

No doctor ever wants to hear that they’ve made the wrong diagnosis or gave the wrong treatment. Yet, errors do happen, and sometimes they turn into complaints. Other times, complaints can emerge even when everything seems to have gone well.How can doctors avoid these situations?At this year’s Rural and Remote Conference in Winnipeg, Wakefield, Que.-based family physician Dr. Mark Saul led a session on reducing errors and complaints. He opened up his talk with an anecdote from early in his career when he accidentally administered the adult dose of intravenous cefuroxime for a pediatric patient.“Maybe I cut the corners a little bit, you get really confident, you get into a groove,” he said. “After it was too late . . . I checked a third time, and I just gave her the adult dose, 20 times the recommended dose.”Thinking this could be the end of his career, Dr. Saul contemplated whether or not to divulge this to his colleagues. Fortunately, he checked to see what could happen and fortunately found that “the risk of harm is zero.”“Errors happen. Undeclared errors happen . . .. It stuck with me pretty much forever and I learned over the years about how you divulge and how you create a culture of divulging,” he said. Today, in addition to being a family physician, Dr. Saul also works as a médecin examinateur—an ombudsperson-like role unique to Quebec designed to investigate healthcare complaints.During his talk, Dr. Saul outlined the some of the major categories of cognitive bias that can lead to physicians making the wrong call. This included situations where a physician might become too attached to the initial diagnosis and fail to consider other possibilities.“Whatever it is, you get told something and that what you’re moving with,” Dr. Saul explained.As an example, Dr. Saul shared another vignette involving a 55-year-old, smoking and overweight man who had never been assessed by physicians. The paramedics said he had “cough and chest pain.” The chest X-ray and vital signs appeared normal and he was sent home, but he was found dead the next day. Participants of the session correctly pointed out that the physician should’ve done an EKG instead of dismissing it as “cough as chest pain.”“We’ll never know if it would’ve told us anything . . . but at least we would’ve been able to say, ‘There was that,’” Dr. Saul said.Physicians having bad estimation of likelihood is another example of cognitive bias. More specific to that, Dr. Saul says physicians can be especially susceptible to hindsight bias, which is when people are convinced that they would have been able to predict a past event after it has already occurred. This can have a negative impact on collegiality among physicians if a patient has a negative outcome because the initial physician fails to make the right diagnosis.“It's easy for us to judge the care of someone that we did not see in that context at that moment,” he said.Ultimately, Dr. Saul says physicians are responsible for the care that they give, not the outcomes. A patient may still die or suffer negative outcomes, even if the care was good. Conversely, a patient may be unharmed after an error, but that doesn’t mean the care was good.“The care should have been better, even if she’s fine,” he said. “You still have to take responsibility.”

A medical ombudsperson’s reminders on reducing errors in medicine

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