My Mistake Museum

Hi everyone,

We all make mistakes. I’ve missed PEs, misread EKGs, and placed needles where they don’t belong. Decades of mess-ups lurk in my brain, reminding me of what can go wrong, despite my best intentions.

We make mistakes because medicine is complicated and we’re human. We owe it to ourselves and our patients to own our fallibility and use mistakes to grow.

Consider these exhibits from my mistake museum:

• That Was Close: When I was a medical student, I volunteered to place an IV, even though I’d never placed one by myself. I gathered the equipment, entered the patient’s room, connected the tubing, swabbed the man’s arm, inserted the catheter, and opened the line. Suddenly, a ball of air started growing under his skin because I’d made two mistakes—one dangerous, one fortuitous. First, I hadn’t primed the line, so I was infusing air instead of fluid. Second, I’d missed the vein, which was fortunate, because otherwise I would have caused a massive air embolism. It was a crucial early lesson: don’t do procedures yourself until you’re ready. If you’re unsure, get help.
• Tombstones: On my first block of internship, one of my patients had chest pain, so I got an EKG and diagnosed “tombstones” across the precordium. Convinced my patient was infarcting, I called my resident, who swooped by and quickly saw that I’d misread the EKG: the “tombstones” were a left bundle branch block. I learned I don’t know everything, never will, and there will always be smart people around to teach us.
• Beware the bezoar: When I was a resident, I had a patient with diabetes who was repeatedly hospitalized with nausea, vomiting, weight loss, and abdominal pain. My co-residents and I dismissed him as drug-seeking. Then, one day, he died, and on autopsy, they found a bezoar in his stomach, the result of longstanding gastroparesis and trichotillomania, which, of course we’d missed. I’d minimized the concerns of a patient who needed my help.
• Yes, worry about it: One of my primary care clinic patients had an alkaline phosphatase in the 300s. She seemed well enough, and I remembered my attending saying high alkaline phosphatases were often non-specific, so I decided not to worry about the result. A few years later, when I was a fellow at Yale, I realized I’d been cavalier and hadn’t considered the possibility of autoimmune liver disease, so I tracked down my former patient in Philadelphia and asked her to get follow up. Here’s the point: non-specific doesn’t mean non-important.
• I thought she had pneumonia: When I was a junior attending, I admitted an elderly woman with hypoxemic respiratory failure. The fact that she had neither fever nor sputum didn’t shake my conviction that she had pneumonia. Even when she died and the autopsy showed a saddle pulmonary embolism, I still wasn’t convinced and asked the pathologist if he was sure. Premature closure struck again: if the pieces of the puzzle don’t fit, question your diagnosis.
• I swear I ordered the antibiotics: About 20 years ago, we admitted a patient with septic shock. Knowing every minute counts, we immediately ordered antibiotics. Hours later, we learned she hadn’t gotten the antibiotics because the first dose was scheduled for the next morning. I still obsess over this case, as I mentioned at Dr. Honiden’s sepsis talk last Friday. It’s not enough to order a crucial medication; you have to make sure the patient gets it.
• He can’t be in shock: Once, a nurse asked me to see a patient whose blood pressure was dropping. I wasn’t too worried, because he’d been stable—so much so that I assumed the blood pressure monitor was calibrated incorrectly. Minutes later, the patient crashed, and I realized I’d wasted time discounting an ominous vital sign. I learned that machine malfunction is a diagnosis of exclusion.
• Failure to proofread: I’m a stickler for accurate notes, and my interns know if I find mistakes in their progress notes, I’ll text them to point them out. In full disclosure, my notes aren’t perfect either, and I may hold the hospital record for returning to previous days’ notes to fix typos. Proofreading is hard, but accurate records are vital. Review your notes, line by line, before you sign.
• Another bout of hypernatremia: Take it from my experience, if your patient can’t drink and you don’t give them water, they’ll become hypernatremic. Every time. Completely predictable. Totally avoidable.
• Don’t forget the nurses: I hereby apologize for every time I rounded with my team and didn’t ask the nurse to join us. You can’t have high quality MICU rounds if the nurses aren’t in the circle, adding to the discussion. That’s how you learn the pressors are back on, the urine output is dropping, and the skin is breaking down on a part of the body you hadn’t seen. You don’t know what you don’t know, but the nurses do.

I could go on, but you get the point. Your error lists are shorter than mine because I’ve been a doctor longer than most of you have been alive. But your lists will grow, because to err is human. As hard as we try to avoid them, we will still make mistakes— many trivial, some serious, all opportunities to learn.

Enjoy your Sunday, everyone. It’s my third weekend in a row on call, and I’m biking down to the hospital join my MICU Red Team.

Mark

What I’m reading:

• Good Writing: 36 Ways to Improve Your Sentences By Neal Allen and Anne Lamott
• Does Matt Damon Look Greek? No. So Stop Complaining About Lupita Nyong’o. By Daniel Mendelsohn
• A Great University Undermines Its Mission By the New York Times Editorial Board
• Kate Heilpern: Redefining the Hospital's Role On Health & Veritas with Harlan Krumholz and Howie Forman
• The Other Procedures We Perform: Teaching the Clinical Skills Families Remember By Harlan M. Krumholz