Guilt, reflection, amends, recovery: What happens after an error?

I recently made an error. I harmed a patient.
 
Now, errors are inevitable in emergency department (ED) practice. I know that.
 
But after the error, I have been reflecting honestly in an attempt to try to learn the hard lessons. It’s all we can do after such an event, after minimising the further harms to the patient.
 
Reflection is important to allow one to learn. Crucially, it allows us to move past the shame and blame and try to make amends. Without reflection, we can get stuck in self-loathing and guilt. So this is my attempt.
 
My error was simple. I placed a central line into a patient’s carotid artery.
 
I have made this mistake once before, nearly 20 years ago when I was a trainee doing quick and blind central lines sans ultrasound on a busy vascular surgery list. Since then I have learned a lot and placed plenty of lines safely.
 
As a rural generalist in a small hospital with our modern approaches to sepsis, I only place a handful of central lines each year. I probably have to supervise more than I actually do and, as such, my practice is sparse.
 
It was the classic error, the one we all fear when placing jugular lines. And yes, it was me – the guy who spends a lot of time thinking about and teaching ultrasound, espousing patient safety and practising procedures.
 
It’s something in which I take a lot of pride. That’s why this error left me feeling profoundly inept.
 
I know the immediate cause of the error. I lost my needle tip as I advanced the wire into the vessel. This is a fundamental sin when guiding a needle – don’t move the needle unless you know where the tip lies. I must have taught this a thousand times, and yet I committed the sin. I then failed to recognise the mistake before proceeding to dilate and thread the catheter.  
 
I wrote a post on simple techniques to avoid this exact error a couple of years ago. The irony.
 
I am sure I neglected much of the content in that post, and I skipped many of the steps. However, it would be wrong to say that this error was due to a lack of knowledge or inadequate skill.
 
This was a cognitive error, a failure to translate knowledge and experience into the safe execution of a task.
 
So the question becomes, why?
Why did this occur on this particular shift? What was happening in my brain that lead me to take short cuts, lose concentration and not recognise the error before it was too late? 
 
To put it simply: Why the brain fade?
 
I will start with a wide view of my internal mental state, and then focus to the actual error.
 
I make no excuses; we all have busy minds and lives. However, I believe it is important to view any error in the context in which it was made. These things do not occur in a vacuum. Understanding the background can help understand the solutions going forward.
 
Life at home is hectic. It is the school holidays and we are in the process of packing up our house to move in a few weeks. Sleep has been broken by excited children, monsoonal storms and on-call duties.
 
Work has been a refuge from the cheerful chaos of childcare. But I have been arriving at each shift thinking about all of the tasks we need to get through to move house after a dozen years of domestic stability.
 
I was working night shifts. Nights in Broome, WA, can go a few ways. Sometimes it is just a slow trickle of drunken injuries and febrile babies, and sometimes it is crazy. This night was the latter. We work solo after 11.00 pm. The four evening staff go home, leaving a single doctor covering the ED, ward and taking calls from the region. Task saturation is never too far off.
 
Handover time is usually a pleasant chat, catch up with the events and discussion of plans. This night was busy. I hit the floor running. All bays were full and there were a series of unknowns in the waiting area.
 
In the wet season, we rely on a series of locum doctors about whom we often know little. This was the case on this shift. I was taking over a busy ED from a team made up of people who were either junior or unknown to me. As I took handover, my inner-monologue was taking notes on all the possible problems and issues I would have to go and check out firsthand, just to be sure.
 
Fortunately, I work with a fantastic team of nurses who make anything possible.
 
The error
There I was, about to place a central line.
 
I remember thinking the angle I was getting was awkward. The IV pole was in the wrong place, but I just decided to work around it, lean in a bit. The ultrasound images showed a deep internal jugular and the neck anatomy made it hard to get a view where the carotid was not partially behind the vein.
 
I should have stopped, rethought, maybe considered another site. But all of the issues for other patients were building.
 
Here is where pride, as they say, comes before the fall. I know this procedure. I practice it. I think I am pretty slick for a part-timer. So instead of calling my mate back to help out in ED, I decided to get it done quickly and get back on the floor.
 
Bad call.
 
I should have recognised that my mind was not focused and back-up would afford me time to do it right. Slow is smooth and smooth is fast. But no, I chose fast over safe in this case.
 
So on I went.
 
The view was okay and I advanced the needle. I got a bloody flash and threaded the wire. After just a few centimetres the wire tickled the heart and we had ventricular tachycardia on the monitor.
 
A quick pull back, but I lost my view in the moment of distraction. The wire must have come back into the barrel of the needle. When I advanced it again it went down easy – but where, exactly, was it going?
 
Here is the thing. In my previous post on this issue, I teach that one should rescan the neck at this point to check the wire is in the vein. But I did not do so. Confident that the line had ‘gone in easy’, I decided to skip that step and move onto dilation. I could hear a few loud yells from the front bays; I wanted to get this done ASAP. The catheter threaded easily.
 
I knew the retrieval team would want to check the line, so I drew a gas and handed it off to the nurse.
 
But the partial pressure of oxygen (PaO2) reading was 200. In disbelief, I transduced the line and the blood pressure was identical to the radial arterial line that I had confidently placed just an hour before. My heart sank.
 
I felt a wave of sweat and nausea beneath my mask. I had harmed my patient. I had made a bad situation worse. Worst of all, I still did not have a decent line to deliver the vasopressors upon which my patient was relying. Now I had even more tasks to complete to get her to safety.
 
The next emotion I felt was anger, or at least frustrated annoyance. Not towards myself, but toward my patient. I imagine that we all feel this at times when things go poorly.
 
But these were dark thoughts that would only lead to dark places. And, after a few deep breaths, I recognised them as such. This was my error. I held all responsibility and needed to fulfil the trust that our patients place in us every day.


 
It was at this point that I realised I was not a superhero. I asked the second-on to be called in. I needed to concentrate and get it right. I needed help.
 
I called the receiving ICU to let them know what had happened and get some advice. Here is where fate dealt me a fine card – the ICU fellow was a gem.
 
He listened and gave simple, pragmatic and sensible advice. He offered to make the calls to the various people who needed to know about my error and could help fix it. It felt like a great burden was lifting. It was not a story I wanted to tell three times.
 
Most importantly, he never questioned the why or how. I did not feel like my competence was under judgement. He assured me it was going to be okay.
 
An hour later he checked in via text to make sure both my patient and I were okay. He had, in short, taken ownership of my problem. It was the most wonderful exchange I have had over many years of speaking to specialists in faraway places. And it is precisely the way I want to help out colleagues in the future.
 
Some days after the event I had the chance to chat with the ICU fellow again. He described his simple approach to helping colleagues who have made errors, or even perceived that they have done so. I want to share his wisdom here:
 
‘There is nothing that one can say or do that will change what has passed. Going over the error, or “Monday morning quarterbacking”, is not helpful in the moment.
 
The actual error is a powerful learning moment for the doctor. More so than any teaching one might offer.
 
The doctor will be feeling awful. Be empathetic to this and acknowledge it.
 
Recognise that there but for luck or fate or divinity, this could have been me on the other end of the conversation. Imagine how you would want to be counselled at the moment.
 
There are many things that one might do or say in the situation. Some will make things better, some will not. Ponder the options and choose the better one.’
 
For me, what helped was being able to follow my patient. After all, they were the one who had suffered here, not I. Checking in and hearing their progress and complications was very helpful for me as I tried to cope.
 
I believe it is common that doctors tend to imagine the worst outcomes when we make errors. That was certainly the case for me.
 
Having actual information to digest and reflect upon further made it a lot easier.
 
The patient did ultimately well. They had to go through a series of steps and procedures because of my error, but, in the end, there was no permanent harm.
 
Once medicine and geography allow, I look forward to having the chance to meet and apologise to the patient face-to-face.
 
As for me?
 
I am emerging after this intense and difficult period of reflection. I feel less isolated after receiving that level of support.
 
I feel more like part of a mangrove forest growing in the murky waters that ebb and flow with the tides.
 
Not alone at all, but part of a community.

A version of this column was first published on Dr Casey Parker’s blog, Broome Docs.
 
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emergency department medical error reflection