Dealing With Medical Mistakes, Facing The Next Shift

Just a couple of weeks ago I dropped the ball majorly managing a patient in the urgent care. All the red flags were there and short of taking a gun and shooting the patient, I did everything wrong.

In this post I want to focus on recovering after a medical fuck up. I’ll discuss the case in more detail and how I could have avoided it. It was harder facing the next shift than it was getting that dreaded email from the QA office.

The Medical Error

I’ve dropped the ball before when managing patients. In some cases I did everything I could, in others a more conservative approach would have been better and in others I just didn’t put 2 & 2 together.

This lady presented with classic symptoms of new onset diabetes. She talked to the advice nurse on the phone who decided to send her in 3 minutes before the urgent care was closing. The patient was having polydipsia, polyphagia, blurred vision, mild dizziness and some weight loss.

She spoke Spanish and I speak adequate medical Spanish. I walk into the room and her husband speaks perfect English so we all start chatting. They were a delightful couple, very friendly and just bewildered by these symptoms.

Her blood sugar was 500 on the glucometer which the nurse did before I even entered the room. The nurse even placed orders for the proper lab work, standard things we test for in anyone with suspected new onset diabetes.

The patient looked great, exam wasn’t impressive though her elevated pulse was regular. No signs of an obvious infection.

We chat a little, I mention having her go to the ED since it was late and if she did the lab work it would take an hour to get the results. They were reluctant, I wasn’t pushy, and they were okay starting on insulin and coming back the next morning for follow-up.

I went home that night without even thinking twice about that case.

I happened to forget to document on her. Nothing, zero, not a word written by me in the chart! I gave her an after-visit summary for generic diabetes but didn’t document shit.

The next morning follow-up

The next morning the patient comes for recheck. Blood tests are done in the clinic, her sodium, potassium and glucose are off by ridiculous amounts.

She appeared much worse and was transferred to the hospital.

Getting the email

A couple of days before becoming aware of this case, I had gotten a different email about a patient complaint with a threat of lawsuit because I didn’t document specifics of the consent before injecting her arthritic MTP joint.

I documented the procedure, the fact that she consented, the fact that she had it done before, etc. She filed the case exactly 1 year after I saw her! Saying that she had pain for months after the injection.

Anyway, that was on my mind but I had nearly forgotten about it. Then I get this email sent to me to review my actions regarding the new onset DM2 patient – shit, I had totally forgotten about her. Meh, what’s the worst that could have happened, she looked better than I did after a night of drinking!

I open the email, I read the questions asked by the review committee – damn, so fucking detailed. Fuck, I bet she died. Pull up the work computer, open her chart… sweet, she’s not deceased!

Looking over the events after I saw her nearly 3 weeks ago was like something out of a horror movie. She presented with confusion the following morning, looking way worse. It went from bad to worse. Blood sugars of 1,000 in the clinic. Sodium of 188?! Slight liver enzyme elevation. Low pH in the hospital. Admitted to the ICU!

These were the questions asked of me:

1. How come you didn’t write a progress note on her?
2. How come you discharged her home?
3. Do you speak adequate Spanish to forgo the translator?
4. Do you think an after-visit summary is adequate for documentation?
5. What was the reasons you didn’t get blood work?

I was just numb, I tell ya. Sitting in front of that screen, reading those questions and wondering what drug I was on when I saw this patient! I didn’t know what to reply to those questions.

This is not my style. Sure, on a patient with eczema or a URI, I might document just enough to qualify it as a note. But when it’s someone this sick I normally document for even the most critical of lawyers.

My immediate mode was to be defensive. Who the fuck had ratted me out? Why didn’t the doctor who submitted this to QA at least give me a heads up?! I have sent plenty of new onset diabetics home in the past without issues! Why am I even doing urgent care? Why didn’t she just go to the fucking ED? Why are they trying to cut a brother down?

Replying to QA emails

This is a good time to address this. As a medical director I have had to deal with these QA cases and review them for the QA committee or with the provider.

Don’t lie

Don’t lie, no matter what… don’t lie. You’re not evil for wanting to lie. Shit, who wants to get caught doing something wrong? When I got that email I was transported back to Dr. Mo at age 8 who had just ran through the glass front door, shattered the fucker and had glass all up in my forehead, legs and hands.

You don’t know who sent the case to QA, the patient or the doctor. You don’t know who else is asked about the case and so lying will without a doubt only hurt you.

And if you lie, your credibility will be shot for the rest of the case. Tell the truth now, deal with it using a lawyer later, if you have to.

Answer only the question – don’t add commentary

ONLY answer what’s asked to you. This is so important for these QA cases. They are internally reviewed by other doctors. Those doctors know that some clinicians will be on the defensive and will try to lie or place blame somewhere else.

I recommend reading the questions and coming back to answer them later or shit, if you have zero tact then have a fellow physician do the writing.

Write out your answers, then go back and pare them down to the specifics. And do everything you can to remove any negative tone from it.

1. How come you didn’t write a progress note on her?
   • I must have completely forgotten.
2. How come you discharged her home?
   • She appeared quite well during the visit and preferred to not go to the ED and agreed to return the next morning for follow-up.
3. Do you speak adequate Spanish to forgo the translator?
   • No, I speak some medical Spanish but upon walking in the room, the husband was comfortable translating for me.
4. Do you think an after-visit summary is adequate for documentation?
   • Absolutely not. Every patient should have full documentation of the history and a full exam to help the next clinician continue their care.
5. What was the reasons you didn’t get blood work?
   • She appeared well and I had no reason to suspect any serologic derangement other than her new onset DM2.

Reply promptly

Don’t wait too long, it’s easy to miss the deadlines in such cases. The committee who reviews these will want your answers to give you the benefit of doubt.

If there is no answer they will assume that you don’t give a shit or that you aren’t even engaged enough to check your work email.

Now, Take a deep breath

I know I dropped the ball. The setting was ripe for me to fuck up. I was excited to get out quick to go shoot pool with a friend. The patient was the last patient who came in after we already closed the doors. Lab was going to take too long to run the tests. I felt bad to send them to the hospital at 10pm.

Now it’s time to pick up the pieces. Sure, I started doubting myself a lot. How many other patients had I fucked over? Maybe I’m a shitty clinician! What if this happens again? Maybe it’s because I am working so little? She could had died. Was I negligent?

The first day back

Yesterday was my first shift back in the urgent care after seeing that patient which was 3 weeks ago. I was dreading it. The few days leading up to it I felt anxious but I was trying to not think about it.

All day yesterday before my shift, I felt anxious and all my feelings of self-doubt started coming back in. I didn’t want to do the shift and I was so afraid I was going to fuck up another patient management.

Don’t doubt yourself

We are gonna make mistakes, that’s part of being human. Regardless of lawsuits and the ridiculously held notion that doctors should be infallible, some of our patients will suffer due to negligent or unintentional clinical actions.

Every mistake is a nudge that will push you in a better direction. Every triumph confirms that you are going in the right direction.

NO clinician gets better without making mistakes. Sure, it’s not talked about and brushed under the rug but I am certain that the reason I am better thanthan some of my colleagues is because I have made far more mistakes than them.

What’s the worst that will happen

The worst case scenario is that you get sued. That’s why you have medical malpractice insurance and solid lawyers who will defend you.

You might get reported to the medical board and they might ask you to take some CME’s on the particular topic.

Your license might get temporarily suspended if your actions were negligent.

Focus on how to improve

Stop worrying about what’s done. It’ll creep into your head regardless, but don’t pay it much attention, don’t keep reliving it.

What went wrong? I lost my medical method because she was my last patient, because I was trying to go along with the path of least resistance, because I ignored my gut instinct, and because I got plain lazy.

A few hours before my shift yesterday, I sat down and wrote out in my journal:

“I am going to go through my routine process with every patient, greet them, get a full history, document as I go, then do my exam, then make my clinical decision and give the patient the option to do whatever they want. I won’t cut corners, I won’t take the path of least resistance, I won’t look at the clock and I won’t put the patient’s life at risk by being cavalier.”

This helped me a ton, I felt ready to go into work and I set up my station the way I normally do. I followed my process for every patient and I did great, I felt comfortable and didn’t feel stressed.

5 steps towards preventing a bad outcome

1. Rule out emergencies

If a patient comes in sweating or with SOB or possible anaphylaxis, get aggressive fast. Accept that this is a potential emergency and manage it accordingly. If you deal with such cases yourself then begin treatment immediately and if you ship such patients out then activate your emergency response.

2. Get a full history

Get a pertinent medical history from the patient or caregiver. Don’t just stick with what the patient said. Let one fact guide you to your next question. Talk less and let the patient talk more. Allow them to warm up to your enough that they will share everything. Trust the patient’s fears if they are valid and don’t dismiss a test that they request unless you are 100% sure.

3. Do a full exam

Put your hand on every patient. Address every abnormal vital sign. Even if you think it’s bullshit to do the exam, go through the motions. It takes 15 seconds to listen to the heart and lungs. It takes 10 seconds to looks in the ears and mouth of a pediatric patient. You can do an abdominal exam in 5 seconds. Do it and document it.

4. trust your instincts

If the patient doesn’t look right, or the case is more complicated than it should be then trust your senses that something is off. Have a colleague go in the room with you. Have the patient get seen by a specialist, run some tests even if to only give you more time to think.

5. arrange follow-up

What if I didn’t tell this lady to come back the next morning? I don’t think she would have had as favorable of an outcome. Most of the patients I see in the urgent care or ED are NOT sick, regardless of their chief complaint. The ones that are, maybe 10%, should have follow-up. Bring them back in, have them talk to a nurse the next day, bring them back to the UC or ED.

Your first day back

Some docs are hit harder than others, especially if the outcome was far worse than my case. I recommend planning for your first day back. Most importantly, don’t be afraid to take a couple of shifts off to get your head on right before going back.

Pick your first day back to work with some good colleagues. Sit next to them, run cases by them. Have your peripheral brain app open and look up everything you need to. Get whatever specialist you want on the phone to run things by them for a second opinion.

Before discharging each patient write your note, start writing your A/P and that’ll be one extra layer of protection, forcing you to think of anything you may have missed in the room.

Set up your space and protect it. Don’t be afraid to say no to nurses interrupting you (respectfully), don’t let someone distract you, don’t take on a difficult case if your head isn’t in the game yet. Never abandon a patient but you can always arrange for care with someone else or somewhere else.

Ignore the pressures and stresses of staff and colleagues. If they want to complain to you about how busy it is, how difficult some patients are or get you involved into their social drama – don’t let them. Walk away kindly and get back to your charting.

Spend more time with each patient, not to the point of getting mislead which is a real issue in the urgent care – but enough that you feel that you’ve addressed everything that needed addressing.

Being more conservative

The side effect of such cases is that we become more conservative. Conservative medicine will deplete resources and expose patients to more intervention but it will cast a wider net and potentially prevent cases, such as this one, from having a bad outcome.

Yesterday, my first day back, I had an 85-year-old patient who presented with his wife at 8:30pm, 30 minutes before closing, for vomiting and slight dehydration. Plain films revealed a partial ileus. The patient appeared incredibly well.

Any other day I would have hydrated the patient, skipped any blood work, done an oral challenge and discharge him home with a follow-up in the morning.

Instead of being cavalier, I chose the conservative route and sent the patient to the ED for a more thorough management including an NG tube, lab work, IV hydration and a 24-hour admission.