When she was a nurse, Karen Frush recalls, she was working with a child in the emergency room. The resident physician asked Frush to quickly grab some heparin flush, a blood thinner used to prevent blockages in IV lines. She ran to the nurses’ station, grabbed the vial and returned to the young patient’s bedside. Within moments, she had drawn up the medication, and the resident began injecting it.
Immediately, the child cried out in pain. The medical team stopped. They all realized what had happened: The heparin flush vial looked remarkably similar to another vial—potassium. In her rush, Karen had gotten the vials mixed up. The mistake would have been lethal had the resident injected the whole syringe. Fortunately, the patient was fine.
Karen was not. Guilt-ridden and fearful about the consequences of her mistakes, she considered quitting. It was only years later, when a national recommendation to separate look-alike and sound-alike drugs was announced, that Karen realized she wasn’t the only one who had made that kind of error.
In the medical world, the saying “To err is human” is associated with a well-known report that emphasizes that errors in health care are more often due to systemic, rather than individual, failings. But admitting that someone was hurt by a mistake that you made, or that was made on your watch, can still be a personally daunting experience. For many, it puts them off admitting errors altogether.
When no one talks about making mistakes, it can seem like you’re the only one struggling. And more importantly, when we aren’t talking about our mistakes, we aren’t fixing them.
Health care has a trust issue
An estimated 98,000 people die every year as a result of medical errors in hospitals. Despite progress being made to make it easier for medical professionals to disclose mistakes, many still hesitate. A 2016 reportfound that 7 percent of physicians think it’s acceptable to hide clinical errors that could harm a patient, and another 14 percent think that it depends on the situation. These are the physicians who admit they would hide mistakes. In reality, of course, the number of people who hide them is higher.
There are many reasons why physicians might hide their own mistakes or cover up for a colleague—fear of retaliation, losing the respect of peers or superiors, lacking time to submit the paperwork, and so on. Even when honest mistakes happen, being open about them can be hard. But the problem isn’t bad people in healthcare; it’s that good people are working in a system where they’re not feeling safe to report errors. And when there’s lack of trust in a system, problems escalate.