In emergency medicine, no one ever wants to make a mistake. We assume worst first because at any minute a life could be at stake. As a resident, I was no stranger to making some mistakes. I had cases with bad outcomes, yet the impact of the cases seemed to always be shielded by the umbrella of working with another attending. I don’t think I ever appreciated how high the stakes were until my name was the sole one on the chart. My first “miss” as an attending made me understand the gravity of even the smallest decisions I make as a physician.
Explore This IssueACEP Now: Vol 39 – No 10 – October 2020
The patient was a middle-aged woman with a history of chronic pain, fibromyalgia, and bipolar disorder who presented with constipation and abdominal pain. She was over a week out from a laparoscopic appendectomy. Prior to her emergency department arrival, she had an outpatient CT for abdominal pain that was negative and she had met with her surgeon the day prior. She reported three days of constipation, two episodes of nonbloody and nonbilious vomiting, and diffuse abdominal pain. She was taking an oral opioid around the clock for pain. Her last bowel movement was the night prior, and she was tolerating liquids. On exam, she was mildly tender to palpation throughout, and her abdomen was slightly distended. My initial thought was that she was suffering from an opioid-induced ileus. I considered a small bowel obstruction, but she was still passing gas, tolerating oral intake, and having bowel movements. Her exam wasn’t worrisome, and she didn’t have any concerning signs of a deeper infection.
Her labs were reassuring, and she had a kidney, ureter, and bladder test that seemed consistent with an ileus. She remained in the emergency department for some hours and, after a few attempts, still could not have a successful bowel movement. I discharged her home with return precautions. Several hours later, she came back in distress. A subsequent CT scan showed a high-grade obstructed volvulus with perforation and a large amount of intraperitoneal air. She was rushed to the operating and had almost 70 cm of necrotic bowel removed. She had a prolonged and complicated hospital course. She would ultimately survive and leave the hospital, but her life was never the same after.
I was devastated after hearing the news of this case. I kept thinking I shouldn’t have let her go. At that point, I was a year out of residency and had no outcomes like this. My confidence was crushed, and I needed to find a way to rebuild. An attending once told me that I would make more mistakes than I could remember and would be named in at least one lawsuit in the course of my career. I remember being skeptical of this as a resident—more so at the notion of making so many mistakes rather than being sued. Of course, no one can expect a physician to make the right decision 100 percent of the time. To err is to be human, of course.
The hardest thing about being a doctor is that you learn best from your mistakes, mistakes made on living people.”
—Dr. Karen Delgado1
What I now find more important is the way in which we address and mitigate our mistakes. Dr. Jerome Groopman poignantly said, “Every doctor makes mistakes in diagnosis and treatment. But the frequency of those mistakes, and their severity, can be reduced by understanding how a doctor thinks.”1 We gain expertise not only through sustained practice over time but also by receiving feedback that helps us understand technical errors, bias, and misguided diagnosis. Self-aware physicians learn to admit to their mistakes, analyze them, and keep them accessible at all times.1
I can now look back at this case and understand that my encounter with this patient was fraught with bias. From premature closure to anchoring, there were so many mental shortcuts taken that could have been avoided. As emergency physicians, we are especially susceptible to cognitive errors and bias. The emergency department is full of land mines that can distract us, be it abrupt traumas, nursing orders, code blues, or belligerent patients, to name a few. One study noted that health care professionals in the emergency department were interrupted 30 times on average in a three-hour work period.2 Despite our work environment, there are a number of ways to avoid errors like this in the emergency department. Asking simple questions such as:
- Am I feeling fatigued right now?
- Was this patient handed off to me?
- Have I effectively ruled out must-not-miss diagnoses?
- More formal checklists can help prevent diagnostic errors.3
We often learn best from our mistakes, yet in our line of work, the cost of mistakes can be high. This was a practice-changing event for me and one that I will likely never forget. I hope to keep my future mistakes to a minimum but appreciate that through these mistakes, I will become a better physician.
- Groopman JE. How Doctors Think. Boston: Houghton Mifflin, 2007.
- Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21(7):535-557.
- Graber ML, Sorensen AV, Biswas J, et al. Developing checklists to prevent diagnostic error in emergency room settings. Diagnosis (Berl). 2014;1(3):223-231.