As a newly minted emergency medicine resident physician, I was excited to help patients in their moments of greatest need.
I vowed to be fully present in every patient interaction, reminded of my own family’s struggles with the healthcare system.
Never could I imagine that just 2 months into my residency, I would commit my first medical error.
Medicine is unique. Our training attempts to mold us into type-A, meticulous humanoids. We prepare for immense stress, learning to make critical decisions in seconds regardless of our need to use the restroom, eat, or get a decent night’s sleep. All the while, we know the consequences for making a medical error are profound. We can and often do cause harm to our patients, sometimes with just a typo on a keyboard.
Long touted as the third-leading cause of death in the United States,1 medical error has caused many to suffer illness and death as they slip through the cracks in our healthcare system. My entire motivation to become a physician stemmed from witnessing these shortcomings firsthand. I have consequently devoted myself to public health, health equity, patient safety, and health system design. Still, I prescribed a patient the wrong medication.
I arrived at my overnight shift and took sign-out for 9 patients, including a middle-aged woman whose only barrier to discharge was waiting for neurology’s final recommendations. The neurology team was overwhelmed with consults that day, and our patient and her husband were angered by the wait, soon becoming verbally abusive. When the neurology team made their recommendations for treatment, I attempted to prescribe the medication and send the patient home. At that moment, a woman brought in for altered mental status incited by drug use began running around our emergency department naked, screaming, “Peel me like a banana!” Another patient threatened my co-resident and attending, saying he would kill them unless he received opiates for his pain and remarking, “Remember this face.” Overworked nurses nearby asked for help obtaining IV access on a patient with difficult vasculature, and another patient arrived in cardiac arrest. I placed the order, typing the first 4 letters and selecting a dose for my patient to relieve her pain that night, attempted to do the same for her pharmacy prescription, and sent my patient home. I then ran to help manage the other crises.
Two days later, I received a call from her neurologist, stating that while my first order was correct, the prescription I sent to the pharmacy was for a completely different medication with almost the exact same name. An autocorrect feature is built into our prescribing system, and in this instance, combined with external distractions and environmental factors, it did more harm than good.
I felt immense guilt for this mistake. While no actual harm was caused to the patient and we caught the error, the emotional and cognitive dissonance of being part of the problem that I have devoted my life to fight has been challenging. I reported the error to my residency and department leadership. I apologized to the patient. I have reflected and have become astutely focused when prescribing medications, triple-checking the correct name, doses, and interactivity with other medications and conditions for each patient.
My department’s medical leadership was understanding, inspiring me with one truth: this error should not have even been possible. Indeed, an industry as bureaucratic and complex as healthcare should have safety mechanisms integrated to prevent such errors. From similar name alerts for medications and artificial intelligence, to review by attending physicians as well as attentive pharmacists fulfilling the orders and matching the medication to the diagnosis, this type of error is easily preventable. The only mitigating factor in this instance included prompt follow-up just 2 days later, a testament to the importance of follow-up. In reality, many of my patients are forced to wait months after their emergency visit to see a healthcare professional.
We are part of a complex, fragmented system of healthcare delivery. This does not excuse our responsibility for our errors, and we must continue to do our best for patients, with an even higher standard of diligence and mindfulness. Yet, system-level solutions are sorely needed and, when implemented, have been proven effective. At some medical institutions, the EMR offers built-in redundancy and advanced analytics to catch medication prescribing errors. At others, close follow-up with specialists and reviews by pharmacists are integrated into the workflow of emergency care provision, demonstrating the power of interdisciplinary collaboration. Local quality improvement committees, utilizing artificial intelligence to flag and audit patient encounters, have proven successful. Despite these improvements, we cannot ignore the unsafe implications of our context on patients and healthcare workers alike.
The COVID-19 pandemic had such potential to disrupt these norms and acutely revealed such issues, yet there has been no change. This is particularly troubling in emergency departments across the nation, currently facing record-high surges in patient volumes, long-term boarding of patients despite being admitted to the hospital, moral distress and burnout, and the increasing incidence of violence against healthcare professionals. These intersectional issues highlight the significance of addressing upstream factors in fostering large-scale system change and quality improvement. Practical interventions, taking into account the environment in which we operate, are critical to protecting the patients we serve.
References
Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016;353:i2139.