Learning from our mistakes makes us better

College of Physicians and Surgeons of Alberta CPSA, Medical Matters, Messenger 12 Comments

I’m a firm believer that if we’re still doing things the same way we did 10 years ago, then we are likely doing them wrong. This is why the College is striving to become more of a learning organization, so that we can continue to improve how we guide the medical profession and protect the public.

As you read through this issue of Messenger, you’ll notice that we have approached something a bit differently. Dr. Lakhani is an Alberta physician who recently went through the CPSA complaint process. We asked him to provide his perspective and share some of the things he learned along the way, so we can all learn as a profession.

This was a case that I believe was not best suited for a disciplinary approach, but for a multitude of reasons, it ended up there. I commend the patient for bringing this issue to our attention, it takes a great deal of courage to do that. Unfortunately, submitting a complaint is currently the only process through which a patient can raise concerns about the quality of their care and I believe this needs to change. In the coming months and years, we plan to look at a process where patients can bring concerns forward as learning opportunities, rather than from a disciplinary perspective.

Saying that, we can’t discount the seriousness of the error made and the effect it had on the patient’s health. Did Dr. Lakhani make a mistake? Absolutely, but it was a mistake that any of us could have made and one we can all learn from so it can be prevented in the future.

As we know from the aviation industry, it is rarely one single event that causes an adverse outcome and in that same vein, there is rarely one single thing that will prevent that event from happening again. In Dr. Lakhani’s case, there are many things that could have been done differently, but that doesn’t mean we should set out to blame others for what happened. If we really want to move things forward, we all need to embrace our own accountability when things go wrong, so we can learn.

In his article, Dr. Lakhani raises some important issues that we need to consider. We need to be vigilant and recognize that health care is a complex environment, which can increase the risk of missing things. We all need to work together and improve our communication as colleagues— we can decrease the chance of errors by talking to each other more. And last but not least, we need to give patients more access to their medical information, because they are the ones most invested in their own health.

Finally, I would like everyone to realize that this was a rare event. As physicians, accepting responsibility, empathetically acknowledging the patient’s suffering and approaching the situation ready to learn from it can lead to a successful resolution. We go into health care to help others and a negative outcome can be devastating. When something goes wrong, it takes incredible courage to move past the negative feelings, but we must all try to acknowledge these mistakes so we can all improve.

I commend Dr. Lakhani for agreeing to share his perspective so that others can learn. I hope others will take this opportunity to reflect on their own practices and identify ways to prevent these very same things from happening.

As always, I appreciate your thoughts and feedback.

Scott

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Nour Eldin Galal

They are highly positive thoughts and could have benefited both Patient and Physician.

Scott McLeod

Thank you for reading and commenting on the Messenger. Scott

Nour Eldin Galal

Thank you for replying to me. Usually in work places, they have what is called Standard Operational Procedure for their workers to follow. When mistakes happened and discovered, they ask themselfes does the worker who commit the mistake follow the procedure or not and accordingly they either reach a point where they either discipline the worker, discipline the worker and amend the procedure or just amend the procedure. In case they amend the procedure they notifiy and train their workers about the amendment. please I suggest to take this model if you see it is appropiate for you.

Scott McLeod

Thanks you for the suggestion. There are many reasons why mistakes happen and rarely can they be traced to a single error in an SOP. As I’m sure you can appreciate the health care environment is very complex and rarely can SOPs provide answers to all the possible situations that may arise. That complexity also means that sometimes there is a requirement to deviate from SOP. Nothing is easy when it comes to mistakes, but I like to see them as opportunities to learn and not punish if at all possible. Scott

Rajesh Sood

All doctors make mistakes and these may have serious consequences. We have to accept this as a society. It speaks volumes about our values when doctors have to be advised not to apologize. Phone calls from colleagues can prevent disasters , however it is impractical to expect a call about every abnormal result. Dr Lakhani raises a valuable point that a charge of “unprofessional conduct” covers too large a variety of “offences”. Should he have the same charge against him as a doctor who commits sexual assault ? I am sure he has berated himself more than any college or… Read more »

Scott McLeod

Good morning Rajesh, Thanks for the comments. The concerns you raise here are exactly why we have taken the approach we took in this addition of the messenger. We want some shared learning to come from this case and not leave it as simply the finding of a hearing tribunal. We as a College have learned a great deal from this case and are taking action to change things. Dr Lakhani was incredibly brave to put himself out there and share his experience to help others. We need to all learn from Dr Lakhani and be more open about the… Read more »

Rajesh Sood

Dr Mc Leod,
Thank you for the reply. Dr Lakhani has been brave to share his experience with his colleagues. However in a 30 year career he now has an “unprofessional conduct” charge against him for an honest mistake.
Does the college truly believe no other doctor may have got away with a similar error ?

It also seems that he was made to go through the costs and stress of a hearing when he accepted his mistake unreservedly.

The college is still criminalizing genuine medical error.
If we are to encourage an open learning culture then this should not happen.

Scott McLeod

Good afternoon Dr Sood, You are correct in pointing out that Dr Lakhani has been though a process that is not the most appropriate for learning from mistakes. As I mentioned in my article above we are all learning from this case and investigating how we as a College can also do a better job with these situations. There are many reason why we ended up where we did that I can’t get into here, but I can assure you of two things: First, this is an incredibly rare event and second, the CPSA will be finding ways of addressing… Read more »

Owen Schwartz

Dr. McLeod I would like to commend you on this approach which shifts blame, shame and fear into positive growth and learning. Offering the patient a choice to engage the physician in a learning experience when there is a perceived error is the sort of communication that encourages nobility and greatness.
As a physician psychotherapist who witnessed the cost of unnecessary psychologic trauma that within corporations, professions and families I cannot say enough positive remarks on this forward thinking approach
Thank you

Scott McLeod

Good morning Owen. First of all thank you for reading the Messenger. It’s always great to get feedback. I’m happy to hear that you feel the approach we’re considering is the right way to go. Take care. Scott

MICHAEL COE

My cardiologist, colleague and friend has again further enhanced his already phenomenal reputation as one of Alberta’s most outstanding physicians. His recognition that his error (in missing a critical incidental abdominal finding documented in an echocardiogram ultrasound report) presents a reminder and learning opportunity for all of us in clinical practice, speaks volumes about this physician. Thank you Zaheer, and thank you Scott for how this was presented.

Scott McLeod

Good morning Michael. Thanks for writing in and commenting. We are incredibly thankful that Dr Lakhani was interested in providing his insights for all of us to learn from. These small things can make a big difference. Scott