Junior doctors make mistakes, and how they deal with those mistakes is of crucial importance. In this dialogue I explore the psychological reaction and coping mechanisms of a Foundation Year doctor who has made a drug error, contributing to the death of a patient. She speaks with her registrar, who has been though a similar experience. As usual, it is fictional, but based on my observations of myself and others since qualifying.
It is worth considering how common drug errors are. Dean et al, in their BMJ paper ‘Prescribing errors in hospital inpatients: their incidence and clinical significance’ (2002) found during a 4 week period, which involved about 36,200 medication orders, that,
‘a prescribing error was identified in 1.5%. A potentially serious error occurred in 0.4%. Most of the errors (54%) were associated with choice of dose.’
Finlay and Ross, in a BMJ editorial ‘Medication errors caused by juniors’ (2008), wrote,
‘Preventable medication errors account for 10-20% of adverse events in patients admitted to hospital… The situation is similar in Australia and the US—medication errors occur in about 1-2% of patients admitted to hospital, resulting in around 7000 deaths a year in the US alone.’
The public are well aware of the potential for harm, not necessarily related to medications, with articles such as this in the Evening Standard (2002), which said:
‘Alarming failures in the education and training of junior doctors could be contributing to the thousands of medical errors, including hundreds of deaths, which occur in hospitals every year…’
The consequences of error are never underestimated by doctors. But the Francis report, in emphasising the duty of candour in admitting mistakes to patients and families, has focussed attention of the subject. It is vital that doctors who make mistakes can admit to them, but be supported while they work through the implications. If there is need for re-training, so be it. If errors seem to be repeated, or the doctor appears unable to accept a need to improve, then certainly their career choice will need to be reconsidered. For the majority of doctors who make a mistake however, it will be an isolated or very infrequent event. The way they deal with it requires some examination. This is how one such doctor deals with it.
Scene: a quiet corner in the doctors’ mess.
An FY1 (Foundation Year doctor, in her first year of employment since qualifying) and her registrar.
Registrar: What happened?
FY1: I made a mistake. A really bad one. Somebody died.
I heard about it. How are you doing?
Awful. I feel awful.
Are you worried? About your career?
Yes, well no, not about being in trouble so much. I know there will be an investigation, but one of my friends did something similar last year…
What happened to him?
He had to go on a course, pharmacology and prescribing, and he had to be observed doing drug charts for 6 weeks. But he got through it.
I can’t guarantee it’ll be that straightforward this time, but you’re right, I don’t see why you should be struck off or anything like that. Not for a one off error. The irony is, however many courses you go on, after this you will never prescribe a drug again without being one hundred percent sure that the dose is right. You’ll be paranoid, but you’ll be safer than most of your mates.
I don’t want to prescribe anything again. I feel sick whenever I see a drug chart now. I’m avoiding writing any prescriptions.
That’s not good. We can’t have you not functioning properly. But it will get easier, I promise.
You’ve had this experience?
Every single doctor you ever meet will have had this experience. Any doctor working in acute medicine will know what it feel like to have done harm.
And how did you cope?
You have to find a way through it. You have to be able to see through it, to the other side. You know you’re going to be a doctor, working for years and years probably, so you have to put it into perspective. But at the same time you can’t ignore the importance of it.
That’s what’s worrying me. I can’t see myself doing this for ever. It’s too painful, having experiences like this. I know, when I think about it, that Mr _ would be alive, now, if I hadn’t written that prescription. Or if I had double checked the dose. He was due to go home in two days! I know that mistakes often have multiple reasons behind them, system errors, but in this case it was me, just me. I actually remember writing it, the word, the number. I can’t handle that, not again.
You are handling it now, in a way. You’re here, at work, not at home sick, you’re talking about it. You’re finding a way through it.
But I don’t want to be here. You know what I want? I want to be home with my Mum and Dad.
That’s natural. It’s a need for security, for comfort. It’s a response to acute stress.
And I keep thinking about dropping out. I have this fantasy of running a book shop, just sitting there, no stress. I walked past one of the cleaners this morning, and I was jealous. I wanted to do her job. No stress. No complications. Simple tasks…
I know what you’re saying, but it’s not real. That cleaner probably has more stress in her life, more persistently, than you do. You are lucky, you have an amazingly satisfying job. You will always be needed, there will always be patients that need to see you. You have been trained to do that job, and I know that fundamentally you enjoy it! I’ve seen you at work remember. You are enthusiastic and genuinely interested. I’ve got no doubt that you’ll be fine.
They won’t be coming to see me! If I’m not there, there will be another doctor in my place. I’m not indispensible.
Of course. Nobody is. But you have the potential to be very good and to be important to your patients, and to the doctors that you in turn will train. The way I think is this, and I know it sounds harsh – but you have a responsibility to get over this setback.
Mr_ isn’t going to get over this setback, is he?
That’s not the way to think about it.
Why? Is my career more important than him?
Of course not. And his death will receive it’s due attention, we will all look at ourselves. Did we train you properly? Was the system for checking prescriptions working? Were the side effects recognised? His death will not just go unremarked. We will, we have, apologised to his family. The coroner will undoubtedly examine the sequence of events. It’s not going to trivialised or brushed under the carpet. But is it right that the mistake should result in a potentially excellent doctor leaving medicine? No, it isn’t. There would be no doctors left!
I feel really uncomfortable with this. It does feel as though we are belittling his memory, focussing on my future.
When I was in your position, years ago, I just kept it all in, didn’t talk about it. Perhaps there’s something to be said for that.
I’m a talker I’m afraid. I have to talk. Do you mind?
No, of course not. Look, this is how it goes. Or how it went for me. I made a mistake, it doesn’t matter what exactly. A patient died. I hated medicine. I didn’t want to come in. I avoided similar situations, just like you have been doing. And then, you know what happened?
Life happened, that’s what. By which I mean, the sun rose and the sun set, shifts came and went, patients arrived that needed to be seen, and they kept coming, and I had to see them and treat them. There was no option. And three weeks later I looked back, and thought – shit, I’ve seen hundreds of patients since I made that mistake, and nothing bad has happened. I felt safe again, in myself. I felt like a safe doctor. That’s how it went for me.
Riding a bike.
Kind of. You have the skills and the knowledge. You have identified something about yourself through this error…the fact that your memory for drug doses is not perfect, and you have learnt from it. Depending on the policy of this trust, which I don’t know, you may have to do some ‘remedial’ course or programme, and if that’s the case, fine, accept it. Penance. But in three weeks, I promise you, the pain you feel now will be a mental bruise. You’ll never forget it, but it will fade.
Easy as that.
Not easy. Because it will happen again. You can’t have a career in medicine, especially a practical specialty, or surgery, if you’re that way inclined, and not cause harm occasionally. Every invasive procedure has a complication rate, by their very nature. The chance that you will be the one who never has a complication is infinitesimal. So you have to find a way to deal with it. It’s going to happen. This is your first time. Your colleagues may experience it this year, next year, in three years time. Perhaps it’s good to go through it now, I don’t know. How are you feeling?
Just as bad.
I can’t change that. But time will.