What to do if you make a BIG clinical mistake.

Oh everyone makes mistakes.
Oh, yes they do
Your sister and your brother and your dad and mother too;
Big people, small people, matter of fact, all people!
Everyone makes mistakes, so why can’t you?
—Sesame Street

I try to be a safe practitioner. I try to be a good nurse.
Even so, I have made many clinical mistakes as a nurse in my 30 year career.

Thankfully most of them have been insignificant.
Some of them (on reflection) have been hilarious. A few of them have been more serious.
One or two of them have been BIG.

There are many reasons (that I wont go into here) why good nurses make bad mistakes. But here is some guidance on what to do when you make mistakes on the i-don’t-even- want-to-think-about-it end of the spectrum.

I really hope you never do. But you probably will. So its good to think about how you will respond.

Mental Hygiene.

There is nothing more awful than that initial moment when you realise you have just made a significant clinical mistake. Your gut goes into fee fall and you feel your life drain from your face.
You may feel tachycardic, and clammy and nauseous.
You may have a sudden feeling of dissociation from reality.
Your brain may be completely frozen in disbelief, or it may react in total panicked hyperdrive.

Remember to reset and re-boot. Take a deep breath.

You are not the first nurse to make a significant clinical error and you will by no means be the last.

But at this moment…..it is not about you. It is about your patient. And there is work to be done.

Respond.

Assess your patient for any immediate or potential consequences that need to be attended to. If you are unsure of what those consequences might be, seek senior assistance. Look at your patients ABC’s. Do a full set of observations.

If there is no immediate threat to your patient, your brain might now want to make your problem go away.

I think everything is going to be OK here.
No need to make a big issue out of this. Lets just let it slide.
Nobody is aware of this mistake. I certainly did not intend to do anything wrong here. Im tired and overworked and I don’t deserve to cop the resulting trouble. Besides, let’s just spare this person all the worry and forget about it.

This is a reaction, not a response.

But wait, you say, I would never do something like that.
Well let me tell you from personal experience, that voice whispering in your ear and looking for the easy path around the situation is mighty sweet and convincing.

But the path of professional accountability does not go around. Only through.

EVERYONE makes clinical errors.
Your first response should be to ensure the clinical safety of your patient.
You must then inform them of the mistake or error.
Seek support from other staff early.
Accurate, objective documentation is essential.
You may require professional de-brief and or psychological support following the incident.

Immediate conversation.

The most important thing to do now is to tell the patient (and their significant others) exactly what happened. As soon as is practically possible.

This will be a difficult conversation. Difficult because you will be feeling so goddamn awful, and difficult because it is from this very place of awfulness you will need to communicate fiercely and effectively.

You may need to have someone with you for support, but it is important that the conversation comes from you.

Try to keep it simple. State exactly what you did wrong. Do not try to justify, or explain why it happened. Do not belittle or over-exaggerate the issue.

Tell them what happened in plain, clear language.

Apologise. From the heart.
Tell them what you intend to do next.
Ask them if they have any questions or needs at this time.

Depending on the situation, the patients response (and that of their family) may range from understanding, to extreme anger, to anxiety and fear. These reactions may occur immediately or over time as they have time to process the information.

Under no circumstances adopt a defensive or argumentative stand. Listen to them.

Seek help.

If you have not done so up to this point, now is the time to seek some assistance. You should notify your team leader and/or senior medical staff of the incident.
They will need to be involved in communications with the patient and in some cases they may need to arrange for someone else to take over their care ( for example: you may need to have a break for a while, or feel unable to continue with caring for this person at this time, or the patient may refuse to have you continue with their care).

Document.

Accurate and contemporaneous documentation of the mistake should be completed in the patient notes. Your documentation around this event is very important and may be reviewed in detail in the future.
So it is important to have time and space to sit down and make a thorough account of what happened.
Again. Keep it clear and concise.

I would also advise you to objectively include any external events or environmental conditions that you feel may have contributed to the mistake being made. If there were any.

Examples of this might be things like workloads, interruptions to workflow, unfamiliarity with equipment, unclear written orders.
Also record the conversation that you had with the patient and your actions immediately afterwards.

It is also a good idea to make a personal ‘diary’ record of what happened. You don’t need to do this immediately. Perhaps sometime over the next few days as the initial emotions settle.
This document should also consist of a factual timeline of what happened for future reference.
It can also include more of a narrative record of of your experience.

After all the documentation and reporting you have done, it might seem a bit onerous to write yet another account of the incident. Especially when you are feeling so rubbish.

But do not underestimate the cathartic effect of writing down your own account of what happened.
If the mistake was a ‘big’ one, a personal record will also be extremely useful to re-jig your memory of the actual events in the future should you need to do so. Sometimes you may be required to recall the incident months or even years down the track.

Report.

Your hospital may have reporting policies for incidents or errors (such as medication error reporting or critical incident reporting). These must also be completed.

Debrief.

OK. So now it can be about you.

You will probably be feeling pretty terrible at this stage. And, truth is, nothing I could write here could possibly make you feel any better.

As the wise folks from Sesame Street assure us, everyone makes mistakes. And that includes big ones. It does not make you a bad nurse. It does not make you a bad person.

The essential thing here, is to find a trusted, supportive colleague and talk to them about what happened.
It is perfectly normal to beat yourself up and question your abilities as a nurse afterwards.

You may also experience the following:

  • ruminating and replaying the event over and over in your thoughts.
  • decreased appetite
  • increased irritability and loss of concentration.
  • not wanting to go to work.
  • problems sleeping.
  • loss of self-esteem or confidence.
  • believing other staff no longer trust you, or are putting you down.

Again, these are all normal reactions that may be experienced after making a clinical error.
However, if they do not begin subsiding after a reasonable time, or if they intrude into your ability to function effectively as a nurse, you MUST seek professional support.
See your manager or senior staff to arrange this. Your workplace should have support services in place.

The long term sequelae will be different for each of us depending on the magnitude of the mistake and the support we receive afterwards.

It may be useful for you to reflect on why the error was made, and become active in developing any quality improvement solutions that might be implemented to lessen the chance of re-occurrence.

Sometimes it will lead to some ‘inner work’ examining some of your own practices or clinical behaviours that might be improved.

Your feelings about this mistake will probably never change.
But your relationship to those feelings will, over time, adjust. With support and self- reflection, the mistake (no matter how large) can be accepted for what it was.

Issues around any adverse outcomes from the mistake can be worked through, and the event can be integrated into your professional work making you even more accountable, compassionate and competent.

4 thoughts on “What to do if you make a BIG clinical mistake.

  1. Just looking at the previous comments I am wondering about our policy of Open Disclosure and our obligations under it ?
    Having been on both “sides’ of an ‘incident’ I agree and support our obligation to comply.
    The first incident involved a total lack of ‘owning’ a mistake, it involved the medical and nursing profession and lead to a cascade of horrific consequences for a relative of mine. Mininmal disclosure was the ‘modus operandi’ and greatly added to our distress.
    The second incident involved me being part of a mistake which thankfully had minimal consequences for the person but I would say pretty severe consequences for me. Again a lack of disclosure enforced by nursing management care contributed to a less than adequate outcome and great distress personally.
    After my experiences I fully support ken and honest disclosure but in real practice I am very aware this is unlikely to occur.

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  2. Yes I would be cautious about informing the patient and family. Most things are better resolved at the hospital level
    Your practice needs to be dealt with on a professional level.

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  3. I would be careful about advising the nurse to give information to the patient and family members. One hospital I worked at made it clear in their policies that the doctor did all the talking. The rest of your advice is good. Yes we all make mistakes. Hopefully we learn and adjust our practice if there were contributing factors.

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