Posted by: GPs To Be28 November 2016
I made a mistake. Well I’ve made several, but this one stands out. One of our sectioned psychiatry patients asked to leave the ward. Not long after he left, we discovered that his right to leave had been suspended the day before. I hadn't realised. His forensic history made the hairs on the back of my neck stand up.
Thankfully, he came back quickly. There was a collective release of breath, a close shave. And then we did what we always do - work out who to blame. We sat in a room, looking forlorn and regretful, trying to avoid catching the eye of the manager. It was like being at school again, when no one owns up to throwing a rubber at the teacher’s back. We were all given a stern dressing down. With lots of mumbling promises that it wouldn’t happen again, we dispersed.
In healthcare, we’re more inclined to drive our mistakes underground
Did the manager have a point? Of course. Did I feel I had learnt from it, would be motivated to look at the system underpinning the error, and work creatively to try to fix it? Not really.
I’ve felt like I’ve just come out of ‘Confession’, writing that. It’s not something we do very often in the NHS, talking about our mistakes. And I’ve begun to realise why that’s a huge mistake in itself.
Starting off in general practice can feel like starting school with shoes two sizes too big, tripping over your feet and skeptical of your mum’s emphatic explanation that you’ll grow into them. You tend to get more wrong than you get right. But before long the cultural insinuation of infallibility creeps in, and your self-esteem is bound up with your clinical competence. Admitting when you’ve made a mistake, even to yourself, feels deeply uncomfortable.
Even spotting your mistakes as a GP isn’t easy. There’s no secure cocoon hovering around you ready to swoop in at the faintest whiff of an error, no immediate feedback from your patients, and no real-time system of pulling the trigger when you spot a mistake. And with hordes of patients trying to get a foot in the door to see a doctor- any doctor- the continuity that lends itself to such rich learning loops seems to be fading too.
When it comes down it, for us trainees on the ground, I’m yet to be convinced that we’re very good at learning from our mistakes. Instead, it feels like our finger-pointing culture encourages the deployment of cognitive filters and the building of defensive walls.
In Matthew Syed’s book, ‘Black Box Thinking’, he proposes that detailed investigation of our everyday screw-ups can prevent recurrences, in the same way that black box flight data has dramatically reduced the incidence of plane crashes. In the aviation industry, near-misses are viewed as the inevitable result of the gap between the complexity of the system and our capacity to understand it. Every error, every failure, and every flaw is seen as a marginal gain.
This feels a world away from my experience. Syed likens our allergic attitude to failure to playing golf in the dark: if you’re not made immediately aware when things don’t go to plan, how do you improve? And for general practice, it's more like wandering through the green before you've even hit the ball, with little chance of working out where you went off course.
In healthcare, we’re more inclined to drive our mistakes underground, to use blame as a way to collapse a complex event into an intuitive, instantaneous explanation. We pin up our thank you cards and congratulate each other on diagnostic pearls. Yet we think much harder before sharing the times when things don’t quite go to plan.
To me, this feels like woeful under-exploitation. Imagine if we could see our errors in a new light, as opportunities to learn and grow from the inevitable failings that result from operating in such an unpredictable environment. If we could trust in the power of our practice, and praised each other for daring to improve from investigations of our errors.
Imagine addressing the mistake I started with, but in this culture. What would that look like? The manager would separate the people from the problem. We would question each link in the chain, from the patient asking his nurse to leave, through to the receptionist who let him out. And looking back, it's clear that the weak spot came from our outdated handover sheet. By the end, we'd walk out of that room waving a plan that the whole team was invested in, feeling reinvigorated in our campaign for zero harm on the ward.
Embracing failure might be a cliché of the business world, but I don’t think we do it enough. We need the intellectual humility and courage to transform the notion of failure from a personal hit on self-esteem, to something that’s inevitable, an opportunity to learn, and a jolt to inspire creativity.
There’s too much at stake if we don’t.
Dr Nishma Manek is a GP trainee in London. You can follow her on Twitter @nishmanek