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At the heart of general practice since 1960

your first... mistake

In a new series on landmark moments in a GP's career,

Dr Melanie Wynne-Jones discusses handling mistakes

Thirty seconds after Mrs Jones left with her prescription for penicillin you realise you forgot to ask about allergies. You check the computer to discover that she is, in fact, allergic to penicillin.

Our first reaction when we discover we have made a mistake is irritation, embarrassment or horror depending on its nature and severity. Unfortunately our mistakes can have catastrophic effects, so it's important to set these feelings to one side until we have decided what needs to be done.

In this case, the most serious outcome is an anaphylactic reaction. With luck by phoning the pharmacist or Mrs Jones's mobile you will be able to prevent this. Not all mistakes need such prompt action, but your risk assessment must be thorough and identify all the possible consequences and solutions.

Mistakes can be errors of commission or omission and have many causes:

 · Knowledge Complete ignorance of relevant facts or simply being wrong

 · Skills Not gathering enough information ­ includes communication skills and

problem solving

 · Attitudes Prejudices, false assumptions, laziness in finding out or using early-warning systems, an inflexible or unsystematic approach: c'est la vie

 · Human error Misunderstandings, lapses of concentration, especially when busy,

angry or stressed (although these are not excuses).

If you do make a mistake, consider:

lwho you should tell

lwhat action is needed

lwhy the mistake happened (knowledge, skills, attitudes or human error?)

lwhat safeguards should be or were in place.

If it is a clinical error you should almost always inform the patient for both ethical and practical reasons. You may be able to present it as finished business (for example, you forgot to refer someone to hospital, but have now made the referral), or you may need to consult the patient before taking further action.

Who else you tell depends on the nature of the mistake, the actions required to rectify it, and your position in the organisation. Most trainers would expect a GP registrar to report any mistake or incident relating to the care of their patients; the same applies if you are a salaried employee. GP principals usually include a duty to inform partners of adverse events in their partnership agreement.

You may also need to inform relatives, primary care and hospital colleagues, the PCT, or even the National Patient Safety Agency1. A sense of proportion should obviously apply.

Most of us are embarrassed to admit to a mistake and it can be particularly daunting if doing so could lead to disciplinary or legal action, but Good Medical Practice2 makes it clear the welfare of existing and future patients must be put above your own. Ring your defence society immediately if you have any concerns; their advice is often reassuring and they will guide you if things get sticky.

Most mistakes can be easily sorted out, yet they may still have far-reaching implications. On a personal level, reflecting on the mistake may highlight a knowledge, skills or attitude problem, or a previously unsuspected educational need. This can be incorporated into your personal development plan.

Clinical governance demands organisations record and evaluate mistakes in a systematic manner3. Formal significant event analysis or critical incident analysis involving one or more members of the practice may uncover deficiencies that should be communicated to everyone; your 'mistake' may provide an opportunity to improve safety for many other patients. For instance, does the practice computer warn about penicillin prescribing in allergic patients? If so, was the allergy missing from Mrs Jones's record, or had you somehow bypassed the warning?

Dealing with your feelings is important at all stages. It is highly unlikely you are the most careless, dangerous, stupid and unworthy GP ever to grace the profession, but it may feel like that, and doctors often find it hardest to forgive themselves. Remind yourself that the person who never made a mistake never made anything.

If you can manage your feelings yourself, fine, but you may need to take a break before your next consultation, or to debrief with your trainer or another colleague4,5.

Dealing with mistakes

 · We all make them

 · Patient safety is paramount and outweighs our own discomfort

 · Safety-netting working habits minimises the risk

 · The most important thing is to put them right and learn from them

References

1 National Patient Safety Agency www.npsa.nhs.uk

2 GMC Good Medical Practice 2001 www.gmc-uk.org/standards/good.htm

3 Clinical Governance www.doh.gov.uk/pricare/clingov.htm; www.doh.gov.uk/clinicalgovernance

4 National Counselling Service for Sick Doctors 0870 241 535 www.ncssd.org.uk

5 BMA Counselling Service for doctors and their families, 24/7, 365 days a year 08459 200169

(charged at local rates)

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