Damage control when you make a mistake?

[deleted836128]

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Sort of a weird question - but - there have unfortunately been a few times usually during winter when I was crazy busy and essentially told the patient “you’re going home” only to realize a certain game changer test was not back and then end up having to change the plan. Hopefully I am not the only one this has happened to, or else I am a hot mess. For example, last night I somehow missed the bottom of a CT report and quickly ran to tell the patient everything looked normal. Now before I officially discharge patients I always do one more review of labs and the full imaging report to make sure I am not missing anything. In this case I read the whole CT report and noted - whoops - the patient had a small bowel obstruction. In my rush to “dispo! Dispo! Dispo!” as admin wants us to do I initially overlooked this. Of course I had to go back and tell the patient to complete change in plans and I felt like an idiot. Unfortunately as we had no beds that patient was one of the ones sitting in the internal waiting room in a chair for six hours so this added more insult. The patient’s family was upset, understandably so. I felt embarrassed as it doesn’t make our hospital look good - or me. And I don’t like letting down my patients. On another night last month the same sort of thing happened with an ankle fracture. Guy was waiting in the internal waiting room for six hours with ankle pain and having to hound the nurse for pain meds, I quickly read the x-ray report and noted a distal fibula fracture so I ordered the splint and told him we would send him home. I then peeked at the actual x-ray films while I was putting in his discharge and noted that he had a tibiotalar dislocation too, and the distal fibular fracture was very displaced and angulated. Requiring reduction. Basically I then told him “change of plans!”, tried to reduce it, was unsuccessful and ultimately had to call Ortho who recommended I admit him for surgery. This poor guy - I told him he was going home and then I completely switched things around. Again, he had a horrible experience in our hospital having to wait in a chair for six hours, his wife was pissed that he didn’t automatically get an ice pack, and the whole situation was just embarrassing.

Do you guys ever experience this? I am feeling like an idiot. Aside from slowing down and being more careful next time to prevent this in the first place - how do you deal with it and still maintain your confidence when it does happen?

 

[gamerEMdoc]

I think honesty is usually best for a large majority of patients. The other day our ED was as busy as I have seen it in years. The waiting room was growing exponentially. People were as frustrated with their wait as I have seen in awhile. But once I acknowledged and apologized about them having to wait, a huge percentage actually apologized to me. Actually apologized to me, feeling bad about how busy the ED was. Pizza showed up at one point after a family member ordered pizza for our dept because they knew how busy we were. It just starts with being honest, acknowledging when their time was wasted, and being honest when minor mistakes get made. You'll be amazed at how many letters to admin that heads off.

 

[Arcan57]

So being honest, acknowledging the impact of the mistake on the patient without trying to blame shift, and accepting the discomfort internally will get you through most of these.

As a question, why are you talking to the patients prior to having reviewed everything? If your errors are all coming from source (prematurely closing the patient encounter), stop doing that. If you don’t remember something cold or know that you haven’t done your final review when the patient is asking for an update then come up with a script that lets you exit the room without being definitive but mollifies them. Same thing when a patient asks you a specific question about one part of the workup you weren’t focusing on (what’s my potassium, how many other stones are still in my kidney). If you don’t have the exact numbwr cold, don’t act like you do. This is especially important in people you’re picking up who have all their labs back when you first see them.

 

[EM Junkie]

Agree with all of the above. With rads studies I’ve on occasion used the following - “You know, I know I said the X-ray/CT was ok - but it was still bothering me that you were in that much pain. Something wasn’t adding up, so I went back and reviewed your images with the radiologist and we found XYZ. I’m so glad that I listened to you and listened to my gut.”

 

[GenericWhiteGuy]

Always look at your images! I cannot stress this enough.

You should have been able to diagnose both a SBO and dislocated ankle fracture on your own. Spend the few minutes to look at the images of EVERY study you order in the ED. We all have stories of picking up “missed” reads from our radiology colleagues. And it is also important that you identify gross pathology that needs intermittent intervention BEFORE an official radiology read arrives (think large head bleed that needs anticoagulant reversal, abdominal perf that needs ABx and surgery, etc.).

Ideally look at studies before an official read and then go back after read and identify what our radiologists have pointed out.

 

[Groove]

Sort of a weird question - but - there have unfortunately been a few times usually during winter when I was crazy busy and essentially told the patient “you’re going home” only to realize a certain game changer test was not back and then end up having to change the plan. Hopefully I am not the only one this has happened to, or else I am a hot mess. For example, last night I somehow missed the bottom of a CT report and quickly ran to tell the patient everything looked normal. Now before I officially discharge patients I always do one more review of labs and the full imaging report to make sure I am not missing anything. In this case I read the whole CT report and noted - whoops - the patient had a small bowel obstruction. In my rush to “dispo! Dispo! Dispo!” as admin wants us to do I initially overlooked this. Of course I had to go back and tell the patient to complete change in plans and I felt like an idiot. Unfortunately as we had no beds that patient was one of the ones sitting in the internal waiting room in a chair for six hours so this added more insult. The patient’s family was upset, understandably so. I felt embarrassed as it doesn’t make our hospital look good - or me. And I don’t like letting down my patients. On another night last month the same sort of thing happened with an ankle fracture. Guy was waiting in the internal waiting room for six hours with ankle pain and having to hound the nurse for pain meds, I quickly read the x-ray report and noted a distal fibula fracture so I ordered the splint and told him we would send him home. I then peeked at the actual x-ray films while I was putting in his discharge and noted that he had a tibiotalar dislocation too, and the distal fibular fracture was very displaced and angulated. Requiring reduction. Basically I then told him “change of plans!”, tried to reduce it, was unsuccessful and ultimately had to call Ortho who recommended I admit him for surgery. This poor guy - I told him he was going home and then I completely switched things around. Again, he had a horrible experience in our hospital having to wait in a chair for six hours, his wife was pissed that he didn’t automatically get an ice pack, and the whole situation was just embarrassing.

Do you guys ever experience this? I am feeling like an idiot. Aside from slowing down and being more careful next time to prevent this in the first place - how do you deal with it and still maintain your confidence when it does happen?

Slow down. Quit pandering to the psychological warfare that the metric nazi's are waging against physicians everywhere. They want to turn you into a factory line worker. Be faster doctor! Be nicer doctor! TATs are 10 minutes higher this month doctor! MIPS are 10% lower this month doctor! Satisfaction is 10% lower this month doctor!

You aren't a f'ing line worker. You're a physician taking care of patients and practicing medicine isn't an algorithm and it isn't a statistical race. Just slow down and quit focusing so much on numbers. Nobody is ever going to likely fire you for being the slowest if you practice good medicine and all things being equal otherwise. It's just a bunch of mind numbing brainwashing tactics to make you produce more for your corporate or hospital masters. These are the last people that will go to bat for you when you have a bad outcome 2/2 going too fast where you missed a critical result.

We all feel the frenetic pressure that you're describing and it really pisses me off that this is what emergency medicine has turned into... a bunch of suits cracking whips over MDs.

 

[southerndoc]

Always look at your images! I cannot stress this enough.

You should have been able to diagnose both a SBO and dislocated ankle fracture on your own. Spend the few minutes to look at the images of EVERY study you order in the ED. We all have stories of picking up “missed” reads from our radiology colleagues. And it is also important that you identify gross pathology that needs intermittent intervention BEFORE an official radiology read arrives (think large head bleed that needs anticoagulant reversal, abdominal perf that needs ABx and surgery, etc.).

Ideally look at studies before an official read and then go back after read and identify what our radiologists have pointed out.

This cannot be stressed enough. I've TPA'd PE's prior to radiology reading the CTA, talked to the neurosurgeon prior to official reads, etc.

ALL films get reviewed by me. X-rays, CT's, everything. For one, it's a learning experience - especially with CT's. Secondly, it's just good care because the radiologist isn't going to get sued if I send home a pneumothorax. It will be me. We're all human and miss things. Radiology is no exception. I've caught missed head bleeds, pneumos, SBO's, fractures, etc. Our radiologists are really good -- most are fellowship trained and we have 3 attendings reading 24/7 (more during the day). Despite this, as I said before, they are human and will occasionally miss something. I'm the one responsible though.

Most of the abnormals get reviewed twice: once by me and another time when I pull up the images in the patient's room and show the patient/family. They love that and it improves PG scores.

 

[LebronManning]

I'm the one responsible though.

Wouldn't the radiologist be primarily liable if a missed read led to an adverse event?

 

[Apollyon]

Wouldn't the radiologist be primarily liable if a missed read led to an adverse event?

No, because the imaging is a "request for radiology consultation". They are, ipso facto, not primary.

 

[Tenk]

Tell them you “clinically correlated” it and found the real problem.

 

[LebronManning]

No, because the imaging is a "request for radiology consultation". They are, ipso facto, not primary.

Right but they're responsible for an adequate read of the imaging, not the ER doc..
If a radiologist messes up a read, I don't see how that's the ER doc's problem if they discharge that patient based on that negative read.

 

[southerndoc]

Right but they're responsible for an adequate read of the imaging, not the ER doc..
If a radiologist messes up a read, I don't see how that's the ER doc's problem if they discharge that patient based on that negative read.

The ordering physician is responsible for interpreting the film or EKG. CT's, MRI's, etc. may have a little leeway, but plain film x-rays were taught during residency and you're expected to read them.

Having performed peer review for a state medical board, I can tell you that it doesn't look good when the plaintiff's attorney asks "Doctor, did you review the x-ray yourself?" and your answer is "No." One case had pages of deposition where the plaintiff's attorney asked if the doc was careless, didn't care about the patient, was too busy to find time to review a life-threatening x-ray for a life-threatening presentation, etc.

 

[DeadCactus]

Wouldn't the radiologist be primarily liable if a missed read led to an adverse event?

Everyone's liable. You can't apply medical logic to law. Guilty until proven innocent and proof comes down to feelings not facts. Emergency physician is liable for not properly interpreting the test they ordered, radiologist is liable for an inadequate consultation, and the hospital is liable for buying a crappy x-ray machine or not staffing enough radiologists. They'd go after the Chaplain for not praying hard enough if there was enough money in his or her pocket.

 

[illegallysmooth]

Yes to honesty. For me this would go "hey! I'm so glad you didn't leave. Your ___ pain was so much that I decided to take another look at these images. Now, the radiologist agrees with me that you actually have ___. Thanks so much for your patience, and I'm sorry for the wait, but I wanted to make sure you got the right care. Here's what we need to do..."

Always always look at your own images. The patient trusts you. But people are only human.