They bear witness to their mistakes

Three health professionals—a surgeon, a pharmacist and a nurse—agreed to talk about their mistakes. Two do it anonymously, for fear of the consequences it could have and one with his face uncovered. Testimonial 1 We do not have the culture of error Naturally stressed, Evelyne * was even more so at the start of her career. While a clinical nurse in surgery, she kept asking the advice of her colleagues for reassurance. “I even called back upstairs in the middle of the night to check that everything was correct,” recalled the young woman, now co-ordinator in another unit. Mistakes, she made a few, but she remembers one in particular during her first year of practice. “The patient was in pain and I asked the doctor to increase her dose of hydromorphone, which she did. When the new medication book came back from the pharmacy, I checked it, but I misread it: I saw 3.5 mL, while it was written 35 mg. During the night, one of my colleagues therefore gave her 35 mg.” The next morning, barely on the floor, she is summoned by her executive. “No empathy, nothing constructive. I wondered if the patient was dead, if I was going to lose my job… I especially felt insulted, because I was not the only one responsible: the resident had written badly and the pharmacist had not checked anything. I had the feeling that we were blaming the rookie. ” Luckily, the patient did not die and did not file a complaint against her. The young nurse, however, lost confidence in herself and kept a certain frustration. “We don’t have a culture of error,” she said. "I was singled out, when the problem should have been dealt with as a team, but there was no post-mortem or follow-up. I found that quite strange.” * The nurse requested that her testimony be anonymous. READ: Avoiding pitfalls in the ED: Recognizing and managing risks of diagnostic error Testimonial 2 Silence breaker Director of the Harvey E. Beardmore Department of Pediatric Surgery at the Montreal Children’s Hospital, Dr. Sherif Emil has always had a unique approach to errors. “It’s normal to do it and it’s just as normal to feel guilty,” he said bluntly. The specialist agreed that this feeling of guilt is not easy to deal with, so he says he speaks openly about it, seeking comfort from family and close friends rather than doctors. “We do not support each other in the profession,” he said, taking as an example two mistakes he made consecutively. “No one came knocking on my door to ask me how I was doing,” he recalled, denouncing a certain lack of humility among surgeons which sometimes leads them to deny that they too can make errors. Recently, Dr. Emil published an article in the journal JAMA Pediatrics titled “Eva’s Legacy.” He recounted the misdiagnosis he made on an eight-year-old girl with very aggressive soft tissue sarcoma. The patient died 18 months later. Although the tumour was associated with an extremely low survival rate regardless of the stage, Dr. Emil was distressed by the initial misdiagnosis and the late intervention. “I wanted to share my experience to honor the memory of this little girl and to break the wall of silence,” he explained. “I have written about a hundred articles and have never been contacted by colleagues. There, I received hundreds of messages from all over the world from doctors who found me courageous, even though they were uncomfortable talking about it. Yet these things happen every day, so why don’t we talk about them more?” Testimonial 3 The drop of too much Marie-Ève asked that her anonymity be preserved, because, following the error made while she was a pharmacist, she decided to retrain in another field of medicine. “My decision was almost made. This error confirmed to me that I had to quit this job.” Working in a medium-volume pharmacy, where she had practiced for a few years, she served an antibiotic that had expired a month ago. “There was no clinical issue. I contacted the doctor and warned the patient, but I did not call him back quickly enough to give him an explanation,” admitted Marie-Ève, who understood the patient’s disappointment. The syndic of the Order of Pharmacists then joined in. “The discussion was very special, 45 minutes devoid of any empathy. You have to live it to believe it. It was infantilizing and humiliating. I was responsible - because, at the end of the day, it is always the pharmacist who is -, but it was more a deficiency in the procedures of the pharmacy than negligence on my part. However, I was made to feel guilty, I was lectured to, in the end, receive a letter of exemption. If I had stayed in the pharmacy, I would have made it my hobbyhorse.” Originally ran on our sister brand in Quebec, Profession Santé. Translated from French.

They bear witness to their mistakes

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