Making a mistake: Some thoughts

Last updated: Sunday, September 25, 2022

Ask for help and act quickly

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You’ve made a mistake and you need to act quickly to minimise the potential harm to the infant. You might want to consider talking to a more senior pharmacy colleague first to ask for help when informing the doctor of your error and dealing with the consequences of your mistake.

In this scenario you must determine whether the mother has taken a dose of codeine, and whether she has subsequently breastfed her child. If the child has been exposed to codeine then you will need to ensure that they are monitored closely until the drug and its metabolites have been cleared from their body. If the mother has taken a dose of codeine but has not breastfed her infant then you should advise that she avoid breastfeeding until she has cleared the codeine and its metabolites.

You’ll have to document the incident in the patient’s medical notes carefully including any remedial action recommended, and ensure that the prescription for codeine is changed to a suitable alternative. Consider whether you should inform the consultant caring for the patient if, so far, you have only been dealing with junior members of his or her team.

Saying sorry

Once you’ve taken steps to try to resolve the situation, then you must decide whether to let the patient know and offer your apologies. Check with the doctor first before you do this.

In this scenario if the mother has taken a dose of codeine, regardless of whether she has breastfed her infant subsequently, she will need to know what has happened and the potential consequences. You’ll have to answer any questions as sensitively as possible and in terms that she can understand. You’ll also need to explain what happens next in terms of whether she should withhold breastfeeding or the additional monitoring that her infant will require. In addition, you should describe the steps you will take to minimise the risk of this error happening again.

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When saying sorry, patients and those close to them, are likely to find it more meaningful if you take personal responsibility for something going wrong, rather than offering a general expression of regret. So you should say: "I'm sorry that I made a mistake with your painkillers", rather than: "Unfortunately, an error has been made on your prescription".

If, in this scenario, the mother hasn’t taken a dose of codeine then you need to use your professional judgement to decide whether you should let her know.  Some patients will want to be informed about ‘near misses’, but others won’t as it may cause them unnecessary distress and confusion. If you are not sure about whether to talk to a patient about a near miss, seek advice from a senior nursing or medical colleague on the ward.

Finally, saying sorry to a patient and admitting you’ve made a mistake is difficult. If you don’t feel that you have the experience to manage the situation alone then take a senior colleague with you for support.

Learning from the mistake

Once you’ve dealt with the immediate clinical consequences of your mistake and apologised to the patient then an important next step is to reflect on what happened. There are two aspects to this: self-reflection and organisational learning.

For self-reflection, you must think through the incident and ask yourself why it happened. Consider the factors that may have contributed:

• Yourself – were you tired/was your mind on other things?
• The task – was it complicated, or difficult to understand? Why did you feel you had to use an old paper resource rather than the BNF online?
• The environment – were you being constantly interrupted? Did other people affect your behaviour?

By considering these three elements you can begin to learn how you work under different circumstances and can take remedial action early to avoid similar situations.

You might reflect that two things influenced how this incident played out. Firstly, you felt under pressure for a quick answer, and people under pressure are more likely to make mistakes. But the answer could have waited a bit. You could have said to the doctor: “I’ll just look into that, and bleep you back in half an hour”. Secondly, why was it that you decided to double-check the information that you’d given after you left the ward? Was there something nagging away that told you it wasn’t quite right or that you’d been rushed? Next time you get that feeling, you will want to double-check first before giving advice.

Organisational learning demands a more formal approach. Depending upon the nature of your error you will sometimes need to submit the details through your employer’s incident reporting system so that it can be formally recognised and assessed. This enables a proper investigation (‘a root cause analysis’) to be undertaken, if required, to understand why the error occurred. Any faults in the system or barriers to safe practice can be addressed to help prevent colleagues making the same mistake.

For example, if staff cannot access the BNF online and old paper copies of the BNF are available on wards then you probably won’t be the first person to have made the mistake of using out-of-date information. You should take responsibility for using an out-of-date resource, but at the same time there should be a proper system for ensuring access to essential online resources and for recalling old paper information from clinical areas. Why couldn't you access the BNF online? Was there a WiFi failure, inadequate PCs on the ward, or was the internet connection too slow? Identifying the problem will help your organisation learn from it.

Rebuilding your confidence

Finally, when you make a mistake it will knock your confidence and, depending on the severity of the mistake and your personality, you may suffer a range of emotions including worry, guilt, shame, stress and disbelief. It’s essential to get the right support whether that be from talking to your pharmacy colleagues, or from outside the department such as through the Occupational Health department or the hospital chaplaincy. Sometimes you might be able to ask for a mentor to assist you. Completing a CPD record may also help you formalise your learning from an incident.

The General Medical Council and Nursing and Midwifery Council’s have joint guidance on being open and honest with patients when things go wrong ('duty of candour'). It includes advice on making an apology and on learning from errors that have been reported. Although it's quite a lengthy document, it's recommended that you look through it. The GPhC has said it endorses the summary statement contained on the first page of the GMC/NMC document.