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Hippocrates’ famous decree, ‘First do no harm’, was an honourable but impossible aspiration.
Hippocrates practised medicine at a time when human dissection was forbidden in Greece. Undoubtedly, the resulting lack of knowledge on disease processes would have led to unintentional patient harm. In medicine, all physicians will inevitably fail to uphold the eponymous oath which many swear to, and this has contributed to the difficult relationship we have with medical error.
Healthcare is an inherently risky activity and cardiology is particularly dangerous due to the conditions that our patients present with and the procedures that we undertake to diagnose and treat them. It is a very uncomfortable situation when things go wrong, but accepting that occasionally they will and having the skills to manage them when they do are both vitally important.
Imagine what you would want to happen if you were a patient or the relative of a patient that had been harmed in the hospital. Most people want to know three basic things:
What can be done to deal with any harm caused?
What will be done to prevent someone else being harmed in the future?
As with many aspects of medicine, effective communication is essential. If something goes wrong, the most crucial thing is to be honest and open with the patient, their family or carer. It is important not to ignore, deny or defend errors that have happened.1 The most senior person involved with the patient’s care should explain what has happened as early as possible in a way that can be easily understood. Whilst the vast majority of errors are due to system failures and multiple people are involved, it is usually only one person explaining what happened, contributing to the discomfort we feel.
The General Medical Council guidance on candour provides detailed recommendations and is a useful and important document to refer to.2 Ideally, the patient or relative should have someone with them for support, and there should be another member of the clinical team present. The discussion should be uninterrupted and should take place in a private room, with everyone sitting down. It is important to apologise early. This is not a legally binding acceptance of blame but is a fundamental human thing to do. The short-term and long-term effects of the error should be explained clearly and an opportunity should be given to ask questions.
After the discussion, the details should be recorded clearly within the patient notes. Providing the patient or relative with a contact number and the opportunity to discuss things later, after they have had time to think of any other questions or concerns, can be helpful. They may want a further face-to-face meeting to clarify these, even several weeks in the future.
After any error and particularly following a procedural complication, debriefs are a valuable way to give feedback and support to all members of the team. It is then important to follow your hospital’s procedure for reporting the error for education and learning.
A period of self-reflection a few days later can be helpful, and writing things down can often help clarify your feelings and concerns. Guilt and fear are common emotions after things go wrong and can lead to loss of self-confidence, anxiety and depression if not addressed.3 Importantly, share your feelings with a trusted colleague, friend or partner to ensure that your worries do not fester.
Finally, do something to look after yourself and take your mind elsewhere, whether that be through exercise, time with your family or friends, or with a hobby that distracts you. It is important that you look after your own emotional and mental health, and seeking help from the occupational health team is not a weakness but an effective way to protect yourself from harm. Interestingly, it has been shown that doctors can thrive following a medical error, provided something positive has come out of it, such as involvement with improvement work or better working relationships.4 Working in partnership with patients who have been harmed may be the most effective way to prevent further errors from occurring.
Important steps when dealing with medical error
Honesty and openness.
Explain the short-term and long-term effects of the error.
Provide the opportunity for follow-up discussions.
Share your concerns.
Look after yourself.
Significant errors in the aviation industry are rare but catastrophic, and the medical profession has learnt a lot from adopting strategies which have been standard practice within the aviation sector for a long time.5 Inevitably, things will go wrong and, despite your best efforts, patients will be harmed during your career. Accepting this and developing strategies to deal with it will help protect you, your colleagues and, most importantly, your patients.
Contributors DMcK wrote this article after being invited to by Dr Sarah Hudson, BMJ Heart Section Editor, Cardiology in Focus.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.
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