The Taxonomy Of Failure
Previously in my post “It’s Complicated…” I introduced the concept of Morbidity and Mortality Report (M&M), and explained it for non-medical persons. As I said then, doctors hate using the word “failure” let alone admitting it. Well we also hate to admit even errors, so even the word “error” must meet rigorous standards and categorization. M&M may require us to discuss complications, but we will go through fairly rigorous debate to determine if, in fact, the complication was the result of an error.
Each complication fell into one of the following groups:
- Technical Error - particularly important for a bunch of surgeons, but any procedure in or out of the O.R. can have an error in technique.
- Error in Judgment - Pretty self explanatory, right? Probably the hardest to admit for doctors who are taught to be infallible, but probably the most important to talk about.
- Patient Disease - A particularly popular category because we get to blame the patient! They were just too sick, too overdosed, or too whatever. The key here is you’re saying it’s the patient’s fault that the complication happened — not the result of a medical error.
- Unavoidable Complication - Sometimes splitting hairs with the “Patient Disease” category, but sometimes things really are beyond the control of doctor, patient, or any other mortal.
Doctors are mostly Type A people, and Type A people love their categories, right? If we can reduce complications to categorized, itemized, depersonalized entries on a ledger, it makes them less threatening somehow. But even for those who can shed complications like changing out of a blood-soaked set of scrubs, the Technical Error or Error in Judgment categories brings that “E” word front and center to all of their peers. Errors happen, even to the most “perfect” doctor. Errors should not be a big deal to discuss.
Doctors have big egos
The result of any of these complications is usually some form of bad outcome to a human being. So discussion can get sensitive, let’s just say.
Don’t forget, doctors have big egos
We, Who Are About To Describe, Salute You
The intended purpose of M&M conferences has always been to promote education, awareness, and most of all, patient safety. That being said, discussion unfolds in front of all members of a department, thus making it a little bit voyeuristic, like a sporting event. A case that gets the attention of the moderator or anyone in the audience may start a clash of minds (and egos). If the person presenting the complications is a junior doc or a resident it can quickly devolve into gladiatorial sport, like prisoners battling lions.
In reverse order of depth/heat of discussion/debate, it often goes something like this:
4. Unavoidable Complications are like a safety valve for complications. They are like the “Acts of God” I wrote about when it came to disasters. Here is a complication that no one, not the hospital, the doctor, the medical staff, not even the patient could avoid. Yay us!…I mean aww too bad for the patient, but yay it isn’t any of our faults! (I’m kidding of course, doctors aren’t this insensitive or fragile. Mostly).
3. Technical Errors surprisingly get the second least attention at Surgery M&M’s. The attitude is usually “Yeah we’ve all done that. Learn from it. Don’t do it again.” There are always some surgeons in the audience who must explain the way he or she does it. They’ll start it with a “Well actually…” But unless it was an error of conspicuous incompetence, most folks in the audience breathe a sigh of relief and silently say “There but for the grace of God…”
2. Errors in Judgment definitely represent red meat for the crowd. If someone made a WRONG DECISION you can bet other doctors are going to make sure they hear it. You thought the mansplaining was bad in Technical Error? It’s even worse here. A lot of chest beating, make no mistake. A particularly bad judgment error would often prompt redundant statements from multiple surgeons feeling the need to explain what the doctor did WRONG. Like wannabe alpha males or females marking their territory, they each have to get their two cents in. I will say this, though. I recall those discussions much more keenly. Testosterone poisoning notwithstanding, I remember the lessons learned from those cases the best. You never forget being “Well actually’d” by an entire department. These mistakes are clearly yours when it’s your decision that caused a complication.
1. Patient Disease isn’t actually the most commonly used category, nor is it always the most discussed. Until it is. Like the name suggests, complications can occur specifically due to the patient’s disease being just too bad to avoid bad outcomes. Sometimes it really is an issue of the patient’s disease being just too entrenched to avoid a complication. And we aren’t actually blaming the patient, so much as taking the responsibility off of us. Yeah, that kind of amounts to the same thing, but we doctors hate to admit error. That’s the whole point of this blogpost remember?
Categorizing a complication as Patient Disease can trigger the most heated debates in an M&M conference for this very reason. If you are going to wash your hands and say “Not our fault; the patient’s disease is to blame,’ you’d better be damned sure that you couldn’t have done anything more or differently to fix the situation before the complication occurred. That’s the point of being a doctor right? To FIX the Patient’s Disease? To classify the complication as “Patient Disease” implies you’ve exhausted all reasonable practices within the standard of care. AND during the conduct of that practice NO errors, technical or judgment, were committed. If you fell short of that standard but were still blaming the patient’s disease…yikes! Release the lions!
A 15cc Dose Of Glucose Helps The Medicine Go Down
As I wrote in “It’s Complicated…” how we deal with errors and yes, deal with failure in general is a very individual choice. All of this very specific criteria for each complication category illustrates my point. Not all institutions do it this way, but breaking it down allows us to compartmentalize bad outcomes into nice tidy depersonalized sugar coated packets much easier to swallow. And we each choose how to take our medicine. We could take it:
With water: Some would present the complication with reasoned analysis, admit if someone was at fault and discuss their insight on the error if error were the case.
With a spoonful of sugar: Others would do just about any mental gymnastics possible to avoid calling out an error: Patient’s Disease, Act of God, somebody else.
Just shove it back as far as it will go, close our eyes, and gulp: Then there were those who preferred to admit an error up front, rather than even hint they were trying to avoid blame. Fall on the proverbial sword; preempt the blame.
A Numbers Game
But why even bother with a classification system at all? Yes we need to discuss complications to better doctors, to avoid the same mistakes, and to identify systemic problems that could be part of a bigger issue. But for each complication why not just say, “X caused Y to happen which led to Z which then resulted in the complication.” Does reducing complications down to statistics and categories strip them of their humanity, thereby removing them of any implication of responsibility or guilt? It’s somewhat rhetorical: We do need to quantify and categorize our complications so that we can identify trends with objective data. So yes, gathering data on M & M’s with categories and stats is worthwhile to track performance. But perhaps it is also a bit of a defense mechanism to convert each event to a number in a spreadsheet column. No matter how poor the patient’s outcome; no matter how blatant the doctor’s error; no matter how trivial a complication; no matter if it was no one’s fault at all; as long as it could fit into a category any M & M was just another “1” to be added to the totals.
In my pursuit of understanding failure, I’m going to guess I’ve spent more time than most of you mulling over the fine details of complications, errors, nomenclature, and classification. It should come as no surprise that I tended to internalize every complication. Regardless of how I presented it at M&M conference, I would always privately find some fault of my own. I couldn’t get even close to the “Just A Number” stage, at least a little bit of which, as heartless as it sounds, is a prerequisite for sanity in doctors. I recognize this as my own shortcoming now, one of the reasons I ultimately quit medicine.
But I’m curious if others in different professions look at errors or outcomes with a similar classification system. Does anyone else jump through mental hoops to avoid saying they made a mistake? I’d love to know if others sterilize their complications as much as an M&M Report could. Are you in such an industry? I’d love to hear from you (hint, hint).