The
aetiology of errors- Wrong identification of problems or diagnosis
- Important task not done, for example, follow up
- Failure to educate patient
- Roles and responsibilities not defined
- Lack of knowledge
- Lack of skill
- Failure to communicate relevant information
- Relevant factors not considered
- Failure to follow up patient
- Management option not considered
- Inappropriate assumptions made
- Failure to resolve uncertainty
- Important decision not made
- Decisions made in the wrong order
- Right tasks done in the wrong order
Any task based on judgment is fallible and errors will always occur. One of the strengths of a group practice is that partners pick up each other's mistakes and can correct the error before serious harm occurs and prevent a recurrence of the same mistake.
Many of the common errors in daily practice can be prevented by improved communication and organisation. Most serious mistakes occur because of poor administration and organisation rather than lack of diagnostic or clinical skills. The willingness to discuss one's own mistakes with partners, nurses, receptionists and the practice manager helps everyone to learn from them. If doctors can admit their mistakes, others will also feel able to do so. It is very important to offer an apology to the patient when a mistake has been made.
To enable us to learn from our mistakes we need:
- Good communication
- Ability to accept criticism
- Continuing professional education
- A forum within the practice where cases can be discussed
- Awareness that sometimes it is better to discuss an error with the individual concerned and not present it to everyone
- A trusting and non threatening atmosphere