We will be performing site maintenance on our learning platform at learn.aaos.org on Sunday, February 5th from 12 AM to 5 AM EST. We apologize for the inconvenience.


Published 11/1/2011
Danielle Ofri, MD, PhD

Owning up to medical error

It was the end-of-the month morbidity and mortality (M&M) conference. The resident had just finished presenting his case: a 31-year-old male admitted to the emergency department (ED) in diabetic ketoacidosis (DKA). Because no intensive care unit (ICU) bed was available, and the ED was overflowing, the team titrated down the insulin drip quickly so they could get a floor bed for the patient. Within hours, the patient was lethargic, tachycardic, and acidotic, resulting in a “rapid response” call and an emergent trip to the ICU.

When the resident finished talking, the chief of medicine reviewed the facts of the case, then said sympathetically, “Welcome to the DKA Club.”

The attending physicians in the room all nodded. No one, it seems, gets through medical residency without mucking up DKA at least once. As the M&M conference wore on, I recalled my initiation in the DKA club.

It was July of my PGY-II year, my first time leading a team. My interns were still stumbling around, squinting in the bright light of clinical medicine. Our patient had been arrested and was thrown into DKA because he hadn’t been given any insulin while in the holding cell. It was a phenomenal teaching case, and I took my time explaining the physiology of the DKA and the insulin drip to my awestruck team.

Within hours, we had revived our patient. He was awake, alert, hungry, and grouchy—all the cardinal signs of cure. When I gave the “d/c insulin drip” order to the nurse, she paused for a moment. “Do you want to give long-acting insulin before you stop the drip?” she asked.

I turned to my intern to capitalize on the teaching point. “The drip gave us meticulous control,” I explained. “If we ruin it with a sledgehammer of long-acting insulin, we’ll bottom out his glucose.” I told the nurse that we’d prefer to just check with hourly finger sticks and give regular insulin as needed.

Predictably, the patient cascaded back into DKA and, when I finally called the medical consult for help, the patient was acidotic, tacyhpneic, and tachycardic.

“What were you thinking?” the consult shrieked at me. She was normally an easy-going person, but she clearly had no patience for this sort of bumbling. “Why the #$%*$ didn’t you give him long-acting insulin before you turned off the drip?”

With my intern next to me, my cheeks burned with shame, and I could not formulate a reply. In fact, I had no idea why I hadn’t given long-acting insulin. Had I forgotten? Had I missed that lecture? Was I simply incompetent?

The humiliation of that moment, of being screamed at in the ED in front of my intern, easily marked the low point of my residency. So low, that I never mentioned it again. So low, that it took 20 years before I could bring myself to speak publicly about it.

Facing up to the shame
When I finally gathered the courage to write about the episode (Health Affairs, August 2010), I found myself reliving the awful emotions of the day. Even with two decades of experience behind me, I still had trouble facing the moment.

I had recently read the book On Apology by Aaron Lazare (Oxford University Press, 2004), a thoughtful treatise on issues of wrongdoing and making amends that is broadly applicable to the medical profession. Shame, Mr. Lazare wrote, is “an emotional reaction to the experience of failing to live up to one’s image of oneself.”

When I read this, the emotions of that long-ago day jolted into focus. It wasn’t the humiliation of being publicly castigated that had devastated me (though that was certainly horrible) but the shame of realizing that I wasn’t who I’d thought I was. I wasn’t the smart, competent doctor at the top of her game that medical school, residency, and my own ego had led me to believe I was. In a single moment, that persona had come crashing down around me, and I was left standing amid the shards of my former self.

Understanding the potency of that moment and the specifics of shame (as opposed to guilt) has helped me realize what might be the most intransigent barrier to correcting medical error. It is shame that prevents medical professionals from stepping forward and admitting medical error. We may improve legislation, initiate systems improvement, codify medical processes, improve mediation—but if we don’t address the issue of shame, none of this will have much impact.

After my essay was published, I received a lot of feedback. Much of it, interestingly, focused on why I hadn’t listened to the nurse, who was clearly more experienced. I don’t think there’s a lot of mystery there—I was a top-form PGY-II with journal articles bulging out of my pockets, and commentary from the sidelines wasn’t about to impinge on my academic frame of mind.

I am older and wiser now and take advice from everyone down to the janitor with a lot more humility. But it struck me that people focused on the “remediable” portion of the story. This, I think, is one of the reflexes that holds us back. There’s always a remediable chink in the complicated cascades that cause medical error. By no means am I minimizing the importance of fixing what’s broken, but the prescriptive approach often glosses over the emotional component.

Recognizing our humanity
Doctors, nurses, and all caregivers are human. Unless we pay attention to the emotional landscape of shame, many medical errors will remain undetected, unaffected by all efforts to reduce error.

In my essay, the only antidote for shame that I could think of was to suggest that senior faculty talk candidly to trainees about their own errors, especially about how they dealt with their emotional reactions.

A month before my essay was published, at yet another M&M, one of the section chiefs—a well-respected faculty member—spoke about a different sort of error. He had made an offhand comment about a patient whose admission probably hadn’t been medically necessary. The tone was slightly disparaging about the admitting doctor. Unbeknownst to him, a family member—who also happened to be a hospital employee—was within earshot. Like wildfire, the comment reached the highest levels of administration.

This physician spoke candidly to the students and house staff about how this had profoundly affected him, causing him to reflect deeply about himself and how he practiced medicine. He admitted that this was the lowest moment in his professional life.

The effect of this story on the audience was palpable. It wasn’t just that his very human story elicited empathy and connection. It was that the trainees witnessed someone who had been through the unenviable gauntlet of shame…and survived. Not only survived, but thrived. Despite all that happened, he was still a successful physician, still a trusted and admired faculty member.

And now, he’d become an exemplary teacher, whose lessons to the house staff would be remembered longer and more profoundly than any algorithm for DKA.

Danielle Ofri MD, PhD, is an Associate Professor of Medicine at New York University School of Medicine and editor-in-chief of the Bellevue Literary Review. Her most recent book, Medicine in Translation: Journeys with My Patients, is about learning the stories and journeys of individual patients. She can be reached at author@danielleofri.com

Editor’s Note: Articles labeled Orthopaedic Risk Manager are presented by the Medical Liability Committee under the direction of contributing editor S. Jay Jayasankar, MD.

Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional.

Email your comments to feedback-orm@aaos.org or contact this issue’s contributors directly.

Additional Resources

Ofri D. Ashamed to Admit It: Owning Up to Medical Error. Health Aff August 2010 vol. 29 no. 8 1549-1551