"I made a mistake!": A narrative analysis of experienced physicians' stories of preventable error.
coaching and mentorship in medicine
diagnostic errors
medical education
medical errors
teamwork
Journal
Journal of evaluation in clinical practice
ISSN: 1365-2753
Titre abrégé: J Eval Clin Pract
Pays: England
ID NLM: 9609066
Informations de publication
Date de publication:
Apr 2021
Apr 2021
Historique:
received:
08
08
2020
revised:
09
12
2020
accepted:
14
12
2020
pubmed:
6
1
2021
medline:
29
7
2021
entrez:
5
1
2021
Statut:
ppublish
Résumé
The complexity of healthcare systems makes errors unavoidable. To strengthen the dialogue around how physicians experience and share medical errors, the objective of this study was to understand how generalist physicians make meaning of and grow from their medical errors. This study used a narrative inquiry approach to conduct and analyse in-depth interviews from 26 physicians from the generalist specialties of emergency, internal, and family medicine. We gathered stories via individual interview, analysed them for key components, and rewrote a "meta-story" in a chronological sequence. We conceptualized the findings into a metaphor to draw similarities, learn from, and apply new principles from other fields of practice. Through analysis we interpreted the story of a physician who is required to make numerous decisions in a short period of time in different clinical environments among the patient's family and whilst abiding by existing rules and regulations. Through sharing stories of success and failure, the clinical supervisor can help optimize the physician's emotional growth and professional development. Similarly, through sharing and learning from stories, colleagues and trainees can also contribute to the growth of the protagonist's character and the development of clinic, hospital, and healthcare system. We draw parallels between the clinical setting and a generalist physician's experiences of a medical error with the environment and practices within professional sports. Using this comparison, we discuss the potential for meaningful coaching in medical education.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
236-245Subventions
Organisme : Royal College of Physicians and Surgeons of Canada
ID : MERG14; PI: M. Vanstone
Informations de copyright
© 2021 John Wiley & Sons, Ltd.
Références
Tien JM, Goldschmidt-Clermont PJ. Healthcare: a complex service system. J Syst Sci Syst Eng. 2009;18(3):257-282.
Kumar RD. Leadership in healthcare. Anaesth Intensive Care Med. 2013;14(1):39-41.
Lipsitz LA. Understanding health care as a complex system: the foundation for unintended consequences. JAMA. 2012;308(3):243-244.
The Royal College of Physicians and Surgeons of Canada (RCPSC). CanMEDS Framework. 2019 Online Available at: http://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e .
Goldberg RM, Kuhn G, Andrew LB, Thomas HA Jr. Coping with medical mistakes and errors in judgment. Ann Emerg Med. 2002;39(3):287-292.
Institute of Medicine Committee on Quality of Health Care in America. In: Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington (DC): National Academies Press; 2000.
Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;3(353):i2139-i2144. http://dx.doi.org/10.1136/bmj.i2139.
Keeney RL. Personal decisions are the leading cause of death. Oper Res. 2008;56(6):1335-1347.
Croskerry P, Sinclair D. Emergency medicine: a practice prone to error? CJEM. 2001;3(4):271-276.
Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard medical practice study I. BMJ Qual Saf. 2004;13(2):145-151.
Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. J Surg. 1999;126(1):66-75.
Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Hamilton JD. Quality in Australian health care study. Med J Aust. 1996;164(12):754.
Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.
Dovey SM, Meyers DS, Phillips RL, et al. A preliminary taxonomy of medical errors in family practice. BMJ Qual Saf. 2002;11(3):233-238.
Pelaccia T, Tardif J, Triby E, Charlin B. An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory. Med Educ Online. 2011;16(1):5890.
Pelaccia T, Messman A, Kline JA. Misdiagnosis and failure to diagnose in emergency care: causes and empathy as a solution. Patient Educ Couns. 2020;103:1650-1656.
Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003;41(1):110-120.
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.
Croskerry P. Diagnostic failure: a cognitive and affective approach. In Henriksen K, Battles JB, Marks ES, Lewin DI, (Eds), Advances in Patient Safety: From Research to Implementation. Concepts and Methodology Vol 2. Rockville, MD: Agency for Healthcare Research and Quality (US); 2005:241-254. https://www.ncbi.nlm.nih.gov/books/NBK20487/.
Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009;84(8):1022-1028.
Croskerry P, Nimmo GR. Better clinical decision making and reducing diagnostic error. J R Coll Physicians Edinb. 2011;41(2):155-162.
Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract. 2009;14(1):27-35.
Chimowitz MI, Logigian EL, Caplan LR. The accuracy of bedside neurological diagnoses. Ann Neurol. 1990;28(1):78-85.
Graber ML. The incidence of diagnostic error in medicine. BMJ Quality & Safety. 2013;22(Suppl 2):ii21-ii27. http://dx.doi.org/10.1136/bmjqs-2012-001615.
Leape LL, Woods DD, Hatlie MJ, Kizer KW, Schroeder SA, Lundberg GD. Promoting patient safety by preventing medical error. JAMA. 1998;280(16):1444-1447.
Schenkel S. Promoting patient safety and preventing medical error in emergency departments. Acad Emerg Med. 2000;7(11):1204-1222.
Romano PS, Geppert JJ, Davies S, Miller MR, Elixhauser A, McDonald KM. A national profile of patient safety in US hospitals. Health Aff. 2003;22(2):154-166.
McNutt RA, Abrams R, Aron DC. Patient safety committee. Patient safety efforts should focus on medical errors. JAMA. 2002;287(15):1997-2001.
Christensen JF, Levinson W, Dunn PM. The heart of darkness. J Gen Intern Med. 1992;7(4):424-431.
Pronovost PJ, Bienvenu OJ. From shame to guilt to love. JAMA. 2015;314(23):2507-2508.
Lander LI, Connor JA, Shah RK, Kentala E, Healy GB, Roberson DW. Otolaryngologists' responses to errors and adverse events. Laryngoscope. 2006;116(7):1114-1120.
Rassin M, Kanti T, Silner D. Chronology of medication errors by nurses: accumulation of stresses and PTSD symptoms. Issues Ment Health Nurs. 2005;26(8):873-886.
Bynum WE IV, Artino AR Jr, Uijtdehaage S, Webb AM, Varpio L. Sentinel emotional events: the nature, triggers, and effects of shame experiences in medical residents. Acad Med. 2019;94(1):85-93.
Shepherd L, LaDonna KA, Cristancho SM, Chahine S. How medical error shapes Physicians' perceptions of learning: an exploratory study. Acad Med. 2019;94(8):1157-1163.
LaDonna KA, Ginsburg S, Watling C. “Rising to the level of your incompetence”: what physicians' self-assessment of their performance reveals about the imposter syndrome in medicine. Acad Med. 2018;93(5):763-8.s.
LaDonna KA, Ginsburg S, Watling C. Shifting and sharing: academic physicians' strategies for navigating underperformance and failure. Acad Med. 2018;93(11):1713-1718.
Prati G, Pietrantoni L. The relation of perceived and received social support to mental health among first responders: a meta-analytic review. J Community Psychol. 2010;38(3):403-417.
Delbanco T, Bell SK. Guilty, afraid, and alone-struggling with medical error. N Engl J Med. 2007;357(17):1682-1683.
West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-1078.
West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294-1300.
Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007;33(8):467-476.
Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf. 2012;21(4):267-270.
Kirch DG, Henderson MK, Dill MJ. Physician workforce projections in an era of health care reform. Annu Rev Med. 2012;63:435-445.
Heiss K, Clifton M. The unmeasured quality metric: Burn out and the second victim syndrome in healthcare. Semin Pediatr Surg. 2019;28(3):189-194. WB Saunders.
Bohnen JD, Lillemoe KD, Mort EA, Kaafarani HM. When things go wrong: the surgeon as second victim. Ann Surg. 2019;269(5):808-809.
Tan EC, Chen DR. Second victim: malpractice disputes and quality of life among primary care physicians. J Formos Med Assoc. 2019;118(2):619-627.
Robertson JJ, Long B. Suffering in silence: medical error and its impact on health care providers. J Emerg Med. 2018;54(4):402-409.
Van Gerven E, Bruyneel L, Panella M, Euwema M, Sermeus W, Vanhaecht K. Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis. BMJ Open. 2016;6(8):e011403.
Van Gerven E, Vander Elst T, Vandenbroeck S, et al. Increased risk of burnout for physicians and nurses involved in a patient safety incident. Med Care. 2016;54(10):937-943.
Rinaldi C, Leigheb F, Vanhaecht K, Donnarumma C, Panella M. Becoming a “second victim” in health care: pathway of recovery after adverse event. Rev Calid Asist. 2016;31:11-19.
Hilfiker D. Facing our errors. N Engl J Med. 1984;310:118-122.
Dubovsky SL, Schrier RW. The mystique of medical training: is teaching perfection in medical house-staff training a reasonable goal or a precursor of low self-esteem? JAMA. 1983;250(22):3057-3058.
Collins ME, Block SD, Arnold RM, Christakis NA. On the prospects for a blame-free medical culture. Soc Sci Med. 2009;69:1287-1290.
Kapur M. Examining productive failure, productive success, unproductive failure, and unproductive success in learning. Educ Psychol. 2016;51(2):289-299.
Clandinin DJ, Connelly FM. Narrative Inquiry: Experience and Story in Qualitative Research. San Francisco, CA: Jossey-Bass; 2000. https://vpor.org/qhd.pdf.
Connelly FM, Clandinin DJ. Stories of experience and narrative inquiry. Educ Res. 1990;19(5):2-14.
Denzin NK. Interpretive Interactionism. Thousand Oaks, CA: SAGE (US); 2001.
Creswell JW, Creswell JD. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. Los Angeles, CA: Sage Publications (US); 2017.
Charon R. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001;286(15):1897-1902.
Creswell JW. Educational Research: Planning, Conducting and Evaluating Quantitative and Qualitative Research. 3rd ed. Upper Saddle River, NJ: Pearson Education; 2008.
Murray M. Narrative psychology. In: Smith JA, ed. Qualitative Psychology: A Practical Guide to Research Methods. London: Sage; 2003.
Mishler EG. Models of narrative analysis: a typology. JNLH. 1995;5(2):87-123.
Caine V, Estefan A, Clandinin DJ. A return to methodological commitment: reflections on narrative inquiry. Scan J Ed Res. 2013;57(6):574-586.
Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. QHR. 2016;26(13):1753-1760.
Zwaan L, Thijs A, Wagner C, van der Wal G, Timmermans DR. Relating faults in diagnostic reasoning with diagnostic errors and patient harm. Acad Med. 2012;87(2):149-156.
Mondoux SE, Frank JR, Kwok ES, Cwinn AA, Lee AC, Calder LA. Teaching M&M rounds skills: enhancing and assessing patient safety competencies using the Ottawa M&M model. Postgrad Med J. 2016;92(1093):631-635.
Short SE, Short MW. Essay: role of the coach in the coach-athlete relationship. The Lancet. 2005;366:S29-S30.
Telio S, Ajjawi R, Regehr G. The “educational alliance” as a framework for reconceptualizing feedback in medical education. Acad Med. 2015;90(5):609-614.
Watling CJ, Lingard L. Toward meaningful evaluation of medical trainees: the influence of participants' perceptions of the process. Adv Health Sci Educ Theory Pract. 2012;17(2):183-194.
Stoddard HA, Borges NJ. A typology of teaching roles and relationships for medical education. Med Teach. 2016;38(3):280-285.
Deiorio NM, Carney PA, Kahl LE, Bonura EM, Juve AM. Coaching: a new model for academic and career achievement. Med Educ Online. 2016;21(1):33480.
Yoon M, El-Haddad C, Durning S, Hu W. Coaching early-career educators in the health professions. Clin Teach. 2016;13(4):251-256.
Palamara K, Kauffman C, Stone VE, Bazari H, Donelan K. Promoting success: a professional development coaching program for interns in medicine. J Grad Med Educ. 2015;7(4):630-637.
de Figueiredo MN, Rodolph B, Bylund CL, et al. Study protocol of a randomized controlled trial to assess the effect of a varied number of coaching sessions on transfer into clinical practice following communication skills training. BMC Cancer. 2015;15(1):503.
Watling C, Driessen E, van der Vleuten CP, Lingard L. Learning culture and feedback: an international study of medical athletes and musicians. Med Educ. 2014;48(7):713-723.
Lovell B. What do we know about coaching in medical education? A literature review. Med Educ. 2018;52(4):376-390.
Watling CJ, LaDonna KA. Where philosophy meets culture: exploring how coaches conceptualise their roles. Med Educ. 2019;53(5):467-476.
Benbassat J. Undesirable features of the medical learning environment: a narrative review of the literature. Adv Health Sci Educ Theory Pract. 2013;18(3):527-536.
MacKenzie C, Chan TM, Mondoux S. Clinical improvement interventions for residents and practicing physicians: a scoping review of coaching and mentoring for practice improvement. AEM Educ Train. 2019;3(4):353-364.
Dowling SK, Mondoux S, Bond CM, Cheng AHY, Kwok E, Lang E. Audit and feedback for individual practitioners in the emergency department: an evidence-based and practical approach. CJEM. 2020;22(4):528-533.
Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med. 2016;91(9):1200-1204.
Cooke LJ, Duncan D, Rivera L, Dowling SK, Symonds C, Armson H. The Calgary audit and feedback framework: a practical, evidence-informed approach for the design and implementation of socially constructed learning interventions using audit and group feedback. Implement Sci. 2018;13(1):136.
Cooke LJ, Duncan D, Rivera L, Dowling SK, Symonds C, Armson H. How do physicians behave when they participate in audit and feedback activities in a group with their peers? Implement Sci. 2018;13(1):104.
Paetow G, Zaver F, Gottlieb M, Chan TM, Lin M, Gisondi MA. Online mastermind groups: a non-hierarchical mentorship model for professional development. Cureus. 2018;10(7). https://www.cureus.com/articles/11233-online-mastermind-groups-a-non-hierarchical-mentorship-model-for-professional-development.