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At the heart of general practice since 1960

We need to embrace failure

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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

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Readers' comments (10)

  • Consistently great stuff as usual, thanks for this.

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  • This is a feature of a good GP surgery, and something to look out for when you are looking for a permanent GP job later on.

    How do they respond to mistakes/ errors?

    My personal reaction has always been to go straight to another of the GPs and talk it through. I know that I am safe to do so - if it is something where I have done something wrong I want help to put it right, and support to remind me that I am actually a pretty good GP the rest of the time.

    In many GP practices you will find this supportive culture - and everyone thinking that could have happened to them, so how can we help prevent it. GP is potentially very isolating, and being in a group where communication is easy is incredibly important.

    Please always remember that if a colleague has made a mistake, and they come to you about it, they are feeling bad and need support. You don't need to lie or say something is OK when it isn't, but you do need to support them in making it right, and remind them about their successes to get some balance back into their view of themselves.

    This is where truly good GPs and GP practices come from - the genuine learning organisation.

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  • Azeem Majeed

    Thank you for your article Nishma.

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  • The thing is, ultimately many of us are afraid:

    We are afraid of being sued; of winding up in front of the GMC; and increasinly of facing criminal charges.

    When facing such (perceived) multiple jeopardy it is hard to maintain an academic curiosity about our mistakes.

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  • Whilst doctors continue to face criminal prosecution for their (inevitable) errors, and compensation- hungry vengeful patients are encouraged to make frivolous claims, then this noble and correct attitude to 'fessing up to mistakes is naive. Even your supposedly confidential portfolio can be raked over by he no-win-no-fee brigade, so be careful what you admit to.

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  • This comment has been moderated

  • The no blame culture does not exist in the NHS. There is a toxic culture of blame backed up multiple jeopardy of complaints to the practices/NHSE/GMC/Ombudsman/healthwatch/CQC and and increasing number of regulators, then the no win no fee lawyer. A simple mistake can drag on for years through all the above. Doctors are not trying to hurt anyone. mistakes happen. You make your assumptions about what any sensible person would do based on that.

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  • Spot on 08:04.
    No one abuses better than other GP's
    It is practices themselves who maliciously refer to all and sundry when they want to blackmail
    or just cause trouble

    All these bodies could not care about truth or justice
    The agenda is to reduce Doctors numbers

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  • TELL IT TO THE JUDGE, I say.

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  • Hmmm, yawn!

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  • Given that even one's reflections in patient care are monitored and need to be "correct" demonstrate that there is no appetite for any self reflection or admission of a mistake.
    That this is occurring and should not be is self-evident. But especially since all junior doctors are only in post for 4-6 months, the attitude of keep quiet and move along would require a massive shake up to shift.

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