Avoiding Medical Errors

[VentJockey]

Today I made a very big mistake. I'm going to be purposefully vague here, I hope you understand. A consult service on my patient dropped a number of notes all around the same time. They had notes for various procedures/studies they did, and then an overall consult note. I spoke to the intern on the consult service, and I *thought* I had read all their notes. But I hadn't. I missed one note, and in it they mentioned a very important diagnosis that requires treatment. The patient was about to be discharged. I had already written my notes and so forth, and I signed out and left for the day. My senior called me, quite perturbed, for obvious reasons. "YOU DIDN'T EVEN READ THEIR NOTE?!"

Ouch. My error. I take full responsibility. Now, I have to figure out a system to make sure this kind of thing doesn't happen again. Luckily, the only harm that this caused was some extra work for my senior and some damage to my reputation. No one died, but obviously patient safety could be compromised in the future.

So does anyone have some tips/advice for systems or techniques they use to avoid OVERLOOKING things in a packed busy case? I'm sure that this sort of thing, where a consult or a lab gets overlooked has come up multiple times for multiple people in the past, so I'm very curious what other people have done to avoid it.

I am very committed to my job. Anyone who can offer me advice on how not to screw up by overlooking things will be my personal hero.

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[cartoondoc]

Checklists have always helped me a lot.

But in all honesty, this wasn't entirely your fault. If it was something *that* important, I think the consult service had some responsibility to communicate it to you verbally, rather than just dropping a note.

 

[hrandani]

Anesthesiologists have done a lot of work in this, and the consensus is this sort of thing is basically an inevitable error due to poor systems engineering. It really isn't your fault, you just have to do twice the work to check everything twice. And of course, that's just not always a feasible proposition when you're getting paged and various services round whenever the hell they feel like it, and attendings feel zero obligation to lift a finger to make your life any easier.

 

[DOk1ng]

Today I made a very big mistake. I'm going to be purposefully vague here, I hope you understand. A consult service on my patient dropped a number of notes all around the same time. They had notes for various procedures/studies they did, and then an overall consult note. I spoke to the intern on the consult service, and I *thought* I had read all their notes. But I hadn't. I missed one note, and in it they mentioned a very important diagnosis that requires treatment. The patient was about to be discharged. I had already written my notes and so forth, and I signed out and left for the day. My senior called me, quite perturbed, for obvious reasons. "YOU DIDN'T EVEN READ THEIR NOTE?!"

Ouch. My error. I take full responsibility. Now, I have to figure out a system to make sure this kind of thing doesn't happen again. Luckily, the only harm that this caused was some extra work for my senior and some damage to my reputation. No one died, but obviously patient safety could be compromised in the future.

So does anyone have some tips/advice for systems or techniques they use to avoid OVERLOOKING things in a packed busy case? I'm sure that this sort of thing, where a consult or a lab gets overlooked has come up multiple times for multiple people in the past, so I'm very curious what other people have done to avoid it.

I am very committed to my job. Anyone who can offer me advice on how not to screw up by overlooking things will be my personal hero.

If it requires treatment, they didn't started it ?

 

[wholeheartedly]

Good book on cognitive errors in medicine. Very readable.

"How Doctors Think" Jerome Groopman

 

[dozitgetchahi]

So the intern you talked to on their consult service didn't feel compelled to convey this very important message to you?

 

[VentJockey]

So the intern you talked to on their consult service didn't feel compelled to convey this very important message to you?

The intern on the consult service just sent me a text page towards the end of the day that said, "Procedure X complete, no disease detected. Note forthcoming"

Kinda sucks :-/

 

[dozitgetchahi]

Yeah, sucks for sure.

Where I am now, a phone call is essentially considered the 'highest' level of communication. For instance, if something is unclear in a note, the first question from attendings is 'did you call them?' If you actually communicated with a representative of their service and they failed to convey this point to you, most people at my program would view that as spectacularly poor form (and a major error) on the part of the consult service.

 

[rokshana]

If it requires treatment, they didn't started it ?

many places, consultive services don't write orders.

that being said, if a consultant is steering the treatment, they should call (not just leave a note) telling someone (usually its the intern taking care of the pt) what needs immediate attention...

as someone suggested, checklists help as well as and reading through anything added to the chart after your last note.

it seems though you did many of the things you should have and could have done...you spoke with the intern on the consult service...he should have pointed out anything that their service want actively done.

and you should document in your note that you spoke with so and so and discussed the case and their recs..may not necessarily change the outcome, but can show that you were thinking about what needed to be done.

and there is a reason you, as the intern, do not have the sole responsibility of taking care of a patient...your senior is supposed to act as your safety net (esp this early in the year) and catch things that may have otherwise been missed...

 

[Dejavu]

Yeah, sucks for sure.

Where I am now, a phone call is essentially considered the 'highest' level of communication. For instance, if something is unclear in a note, the first question from attendings is 'did you call them?' If you actually communicated with a representative of their service and they failed to convey this point to you, most people at my program would view that as spectacularly poor form (and a major error) on the part of the consult service.

Where I work, even at the consultant (our name staff physician) level, but definitely at the resident level, a face-to-face is considered the 'highest' level of communication.

While a person does have the responsibility to read notes from consult services, if some medical point is so important that your reputation rides on it, the intern on the consult service bears some responsibility for communication.

 

[DoctorDermis]

Today I made a very big mistake. I'm going to be purposefully vague here, I hope you understand. A consult service on my patient dropped a number of notes all around the same time. They had notes for various procedures/studies they did, and then an overall consult note. I spoke to the intern on the consult service, and I *thought* I had read all their notes. But I hadn't. I missed one note, and in it they mentioned a very important diagnosis that requires treatment. The patient was about to be discharged. I had already written my notes and so forth, and I signed out and left for the day. My senior called me, quite perturbed, for obvious reasons. "YOU DIDN'T EVEN READ THEIR NOTE?!"

Ouch. My error. I take full responsibility. Now, I have to figure out a system to make sure this kind of thing doesn't happen again. Luckily, the only harm that this caused was some extra work for my senior and some damage to my reputation. No one died, but obviously patient safety could be compromised in the future.

So does anyone have some tips/advice for systems or techniques they use to avoid OVERLOOKING things in a packed busy case? I'm sure that this sort of thing, where a consult or a lab gets overlooked has come up multiple times for multiple people in the past, so I'm very curious what other people have done to avoid it.

I am very committed to my job. Anyone who can offer me advice on how not to screw up by overlooking things will be my personal hero.

In my honest opinion, your Upper level is just as guilty since the upper should also have a grasp on the course of care of the patients. The Upper level should run the list after rounds with the interns to double check on what needs to be done or if anything was missed. Prior to discharging complicated cases, the Upper level and Intern should touch base to make sure the patient is appropriately cared for.

I have learned a tremendous amount through this system of oversight from the upper level, and would hate to have it any other way.