Oct 21, 2015 | Akhil Narang, MD and Bryan Smith, MD
Career Development

I should have asked but I didn't. I was about to perform a cardioversion on a patient who was in symptomatic atrial fibrillation. I discussed the procedure with the patient including the risks and benefits. She signed the consent form as the nurses obtained IV access and positioned the defibrillation pads. I then asked the team of nurses to administer mild sedation prior to defibrillation. The team drew up the medication and gave her an IV push. It crossed my mind to inquire how much was being given, but I didn't ask.

Within seconds, the patient became hypotensive and unresponsive. We immediately cardioverted her back into sinus rhythm, but her hypotension persisted and she was unarousable. That push of medication began a cascade of events that would ultimately lead to her death later that day. After the fact, I learned that she was given 15 times the standard dose of fentanyl and five times the standard dose of midazolam. The overdose of medication was a medical error that likely contributed to her untimely death. I learned many valuable lessons that day. However the one question that lingered in my mind was: Why didn't I ask how much sedation was being given? I should have asked but I didn't.

If you don't find your mistakes every day, it's not because you're not making them. The inevitability of making a mistake is sobering. Progressing from medical student to resident and then from cardiology fellow to attending, we cannot escape the reality that we will make mistakes. The oft-cited statistic that more than a quarter million Americans die yearly from medical errors fails to account for the countless lives saved subsequent to the lessons learned from prior miscalculations. Any FIT or early career attending can attest to the immense apprehension of making a mistake, and every physician has anecdotes of medical mistakes that have resulted in poor outcomes. Despite the utmost attention to detail, countless hours spent attempting to master cardiology, and the best of intentions, we will continue to err. Espousing our errors at each stage of our career is imperative to ensure continued growth as cardiologists.

To the layperson, physicians appear to be all-knowing sources of medical knowledge and expertise (though this perception has likely shifted in the era of online medical resources). However, as a trainee, despite our considerable autonomy, our relative inexperience increases our susceptibility to making mistakes. In addition, most cardiology training programs operate according to graduated responsibility. The best way to learn how to perform a transesophageal echocardiogram, cardiac catheterization or a device interrogation is first through observation and then direct hands-on training overseen by an attending physician. The trainee is truly a novice and only becomes an expert after repetition and feedback, a process that takes time.

The high degree of complexity of many cardiology patients results in a narrow margin for error. One small agitation in a patient's hemodynamics can have catastrophic consequences. Dissecting the anatomy of an error allows fellows to better understand their effects. Generally the biggest challenge is the initial recognition of a mistake. As a fellow, it's reassuring (albeit uncomfortable) when an attending recognizes an error before it impacts a patient; however, this lifeline often expires upon completion of training. More commonly, mistakes are identified when patient outcomes are deleteriously impacted. Whether it's a misinterpreted electrocardiogram that delays intervention or a missed opportunity to optimize medications in a readmitted heart-failure patient, we frequently first learn of our errors when patients fail to get better or get worse. Even in these situations, we may rely on others to point out adverse outcomes.

The next layer in the makeup of a mistake is accepting that one has occurred. There is no substitute for careful chart review and discussion with colleagues when a patient has an adverse outcome. In the majority of cases, no error is found and the patient's course is a result of disease progression. When an error is identified, the initial reaction can be to justify the series of events that led to the error.

Personal acceptance of a mistake is difficult for a fellow or early career attending. It can bruise our pride and call into question our capacities. As an FIT, it is important to remember that introspection and humility are of utmost importance when learning from mistakes. Previous studies have indicated that physicians rarely disclose their mistakes to colleagues and friends, and this can result in significant emotional distress. Making mistakes often paralyzes the trainee who then becomes afraid to make decisions in the future. Nonetheless, when viewed as an opportunity to learn and avoid future errors, owning one's mistake ultimately is much more rewarding.

Disclosure of medical errors, regardless of how small or large, is vital to the culture of transparency in medicine. Previous studies have shown that medical malpractice lawsuits are more common when there is not full disclosure to the patient and family. National surveys indicate that physicians fear admission of errors may implicate them in negligence or wrongdoing, resulting in a medical malpractice lawsuit. To that end, at least 36 states have adopted "I'm sorry" laws, which prevent any apology or admission of wrongdoing to be used in a malpractice lawsuit after a medical mistake. Though providers may feel embarrassed or vulnerable when a medical mistake occurs, these laws demonstrate the value to all parties when transparency exists.

Beyond disclosure to the patient, fellows have the opportunity to acknowledge mistakes to one another and to faculty members. Through formal morbidity/mortality conferences, root cause analyses, or through informal conversations, every opportunity should be made to discuss how and why errors are made. Discussing errors should be done in a careful manner in which blame is not unduly assessed. The culture of talking openly about mistakes should not be taboo. In fact, the simple act of discussing mistakes is often cathartic.

Finally, at the core of making a mistake is the prevention of subsequent errors. The ultimate efforts after identification and acceptance of mistakes should be directed towards ensuring similar errors are not made in the future. When adverse patient outcomes occur, the resultant disheartenment (and even fear) may transiently heighten awareness to ensure that similar mistakes are avoided in the short term. Translating short-term improvements into long-term, sustained changes is more challenging. As a fellow, beyond relying on conferences to reinforce learning points when mistakes occur, a concerted effort must be made to periodically audit one's own practice. Whether that includes formal chart reviews of certain ambulatory patient populations or informal review of inpatient consults at the end of a rotation, fellows, early-career attendings, or seasoned cardiologists all benefit from audits to ensure adherence to standard practice and published guidelines. Self-analysis generates questions about patient care and allows for ongoing dialogue with senior cardiologists.

Many of the errors encountered in fellowship training or just afterwards (and those that cause the most anxiety) center on medical decision-making. Timely and effective communication between health care providers and patients is often overlooked as a major factor in propagating mistakes. As a fellow, we are often the primary point of contact between the attending, consultants, family members and other trainees. Ensuring continuous and open communication with all parties inevitably allows for smoother execution of plans and provides some protection from criticism that may arise if adverse outcomes occur.

Cardiology is a field that requires a combination of thoughtfulness and decisiveness. As trainees, we are constantly working to find the appropriate balance between these two forces, and along the way, making mistakes is inevitable. The image of the perfect physician is a flawed one, an antiquated remnant of the past. Instead, we should view ourselves as lifelong students who are not afraid to admit our limitations, learn from our mistakes, and when in doubt, always ask the question.

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This article was authored by Akhil Narang, MD, and Bryan Smith, MD, fellows in training (FITs) at the University of Chicago Medicine.