• Lead by Example: Train Students to Report Medical Errors

    Health Leaders Media recently reviewed a study that involved medical student observations of errors in the clinical setting. For me, it conjured up memories of similar events I witnessed when I was that "fly on the wall" (disguised as a medical student) buzzing through hospital corridors, seeking new knowledge while following seasoned physicians and watching for clinical pearls I could scoop up for future use. 

    The article -- which details the findings of a study published Sept. 14 in the American Journal of Medical Quality -- also immediately made me recall a chapter from The Checklist Manifesto: How to Get Things Right by Atul Gawande, M.D., M.P.H. The author provides an account of how a timid co-pilot recognized that an airplane captain had unwittingly made a critical technical error. However, out of respect for the pilot he said nothing, and all aboard the plane lost their lives because of the co-pilot's silence.

    In the study, medical students were surveyed about their perceptions of quality and care provided to patients by physicians. Of those surveyed, 90 percent reported observing adverse events. However, only 51 percent indicated that they were comfortable reporting any of these incidents to their supervisor.

    This begs the reader to ask oneself, "What would I do? If placed in the same position as that co-pilot or that fly on the wall, witnessing what I perceived as an adverse breach of protocol or procedure, how would I respond?" 

    This conundrum is not unique to the current generation of medical students. Similar articles of concern have been authored in the past. More than a decade ago, a case study concluded that medical students are often overlooked as valued participants in ensuring patient safety.

    Students entering the medical profession often fail to appreciate the fact that they will frequently witness the raw art of medicine being practiced in a real-world setting. They quickly learn of obvious incongruities between what has been taught in the more sterilized and structured preclinical environment and what they witness in an actual clinical setting. For example, you recall that we were admonished to warm our stethoscope and place it on the patient's skin when we are listening for those critical breath sounds and heart murmurs. So it stands to reason that students are shocked the first time they witness their attending physician listening to a patient's lungs and heart without having the patient remove his or her shirt.

    In these physicians' defense, not everything that I, as a novice learner, perceived as an adverse event was a genuine mistake. I simply did not know what I did not yet know about the acquired art, skills and subtleties of medicine.

    One preclinical module that is omitted from medical school training is how to precisely recognize adverse clinical events and how to report them in an appropriate manner. The Joint Commission Journal on Quality and Patient Safety published a small study in 2007 documenting the attitudes of medical students and house staff regarding medical errors. The authors concluded that exposing trainees to adverse clinical events actually had a negative effect on both their attitudes and competencies and, subsequently, decreased the likelihood of their reporting errors and being willing to adopt safety practices.

    The study echoed the need for this preparation to begin in medical schools by implementing a sustained patient safety curriculum that promotes learning to recognize and appropriately intervene when an adverse clinical event is witnessed. With this seed planted in the formative years of students' medical education, they will arrive at their postgraduate years with a positive attitude regarding how to identify adverse clinical events and how to appropriately intervene.

    In an article published in Medical Education in 2008, an analysis of medical student essays concluded that the medical community continues to miss opportunities to engage students on how to respond to and learn from observed errors. When students observe what they perceive to be medical errors, it's important for educators to candidly discuss such situations and provide them with an opportunity to learn from the outcome of any resulting clinical misadventures.

    After going to several morbidity and mortality rounds as a student, I finally realized the not-so-hidden agenda of these meetings was to share information about how a case went poorly and seek the shared wisdom of seasoned physicians and surgeons regarding how best to prevent it from happening again. This experience added value to my professional development. 

    The house of medicine continues to strengthen its foundations with added attention to quality improvement. Postgraduate medical residency programs have begun participating in recurring Clinical Learning Environment Reviews conducted by the Accreditation Council for Graduate Medical Education. This process brings us one step farther on a journey that we acknowledged needed to be taken decades ago. For the benefit of our patients, it is a journey that must begin with our students being made aware of their responsibility for monitoring clinical quality. 

    Each and every student of medicine must be made acutely aware that if we are to maintain the sacred trust of the public, quality must be the star by which we are guided. As educators, we should never feel threatened or offended by a student who challenges us by asking why we are doing something a certain way. Sometimes it is nice to have that fly on the wall buzz by our ear to wake us up to the reality that there just might be a better way of doing something.

    We are privileged to be in a profession where patients literally entrust their lives to us, asking only that we take action using the best evidence and judgment we have at our disposal. 

    As we continue on our collective journey toward quality improvement to better serve our patients, I challenge our students to be an essential part of that mission. Never be fearful to allow your voice to be heard. When you see something, say something.

    Gary LeRoy, M.D., is a member of the AAFP Board of Directors.


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