Responsibility and reflection: Understanding our responses to perceived errors. A response to Woodward, Lemer and Wu

Abstract

A fourth-year medical student in the USA assumed responsi-bility for a patient with esophageal cancer as a member ofa consultation team. In her initial examination, the student notedasymmetric, non-tender lower-extremity swelling. She docu-mented the edema in her note but did nothing additional with thisinformation. Her teamwas focusing on pain, and she assumed thattheprimaryteamwashandlingday-to-dayoncologicconcerns.Fivedays later, with a change of members in the primary team, a newintern noted the swelling, ordered an ultrasound, and a lower-extremity deepvenous thrombosiswasdiagnosed.Afamiliar seriesof events unfolded: the student recognized her lapse as an error;she felt deeply ashamed and guilty; she worried that her error hadled to a delay in diagnosis, and that this had caused preventableharm to the patient. She reported her error and sense of shame toher attending, and asserted the desire to disclose and apologize forthe mistake to the patient. The attending physician agreed thatwhile an error had been made, there were mitigating factors. Theattending shared her own experience of committing a moredevastating mistake as a young trainee. The student perceivedthese words as comforting and supportive, but the feelings ofshame persisted even after she disclosed the error to the patient.Internally, she vowed never to ignore asymmetric edema.Were there systemic factors that contributed to this error?Absolutely. None of the many other participating physicians hadreadthestudent’sdocumentationofthephysicalexamination,onlythe assessment and plan. The likely harried initial primary internhad not noted the edema himself. A change in teams broughta change in perspective, bringing new information to bear. Thestudent’sformal educationdid notemphasize asymmetric swellingas a never-miss symptom. As the first author of our article in thisissue of Social Science & Medicine ‘‘On the Prospects for a Blame-Free Medical Culture’’ (Collins, Block, Arnold, & Christakis, 2009),the student described above likely understood more than theaverage student in her position about blame and the systemicprevention of error. But this did nothing to prevent her fromexperiencing this mistake as deeply personal, and from acceptingcomplete responsibility for it herself.Inhighlightingthelimitedprospectsforablame-freeculture,ourgoal is not to prevent progress in the error prevention movement.