We ran a ‘fitness to practice’ session at our weekly Half-Day Release session recently. Fitness to practice is the doctor’s awareness of when his or her own performance, conduct or health (or that of others) might put patients at risk and the action taken to protect patients.
The current culture of doctors doesn’t promote talking about mistakes in order to learn from them and make things better. The current culture (especially in hospitals) is often focused on protecting the bigger organisation and laying blame and shame elsewhere (often on the individual).
We live in a world where mistakes are going to happen. That’s not to say we simply accept that they happen and take a laissez-faire approach but rather that we need to talk about these mistakes openly with our colleagues in order to be able to learn from them and make things better. In the current climate, someone is blamed, that person feels ashamed and falls into a cycle self-deprecation whilst the bigger organisation just moves on. That’s not good for anyone!
One of our trainees found this video clip. In it, Brian Goldman (an emergency physician in the US) says every doctor makes mistakes and that medicine’s culture of denial (and shame) keeps doctors from ever taking about those mistakes, or using them to learn and improve.
I hope this clip helps illuminate the true spirit behind things like Significant Event Analysis rather than the formulaic and mechanical ways in which they are often played out.