A Mistaken Identity 

Hudson Bay clouds

My heart sank into the floor.

“You did what?”

“I gave the wrong immunization! I didn’t look close enough at the orders.”

The baby ended up getting a double dose of one of the routine childhood vaccinations because my medical assistant gave the wrong combination vaccination and overlapped. It was not a terrible error, as far as medical errors go, and would not cause harm but try to convince a parent who has gone through multiple miscarriages and IVF to get this one beautiful baby boy. It was not a phone call I looked forward to making.

I could ignore that it happened, sweep it under the rug so to speak. Make it disappear. They would never know….

Still it had to be done. They had the right to know. So I did it. I called and explained and reassured. They seemed to take it very well at the time, or so it seemed.

I see FOUR generations of this family. 

Four.

Or rather, saw. 

They left my practice. 

To be honest, if it were my own kid I would have probably not been nearly so nice about it and I would have also taken my kids elsewhere. I am not upset at this family at all. It hurts but I totally get it. 

Trust is gone.

This was the first time an incorrect pediatric vaccination was given by a staff member to my knowledge in my practice. Fourteen years. That means nothing when it’s your kid. One mistake. Made by one of the best medical assistants we have, the absolute last person I would have expected to make an error. She will carry that one around for a very long time. 

So will I.

We can learn from every mistake, can’t we? 

If I told you I had never made a bad call or made a mistake myself I would be lying to you. There is no perfect doctor. Sometimes we lie to ourselves. Sometimes we lie to other people. That is how we keep going each day. We are not perfect. I know each and every mistake I have made over the years and they play in my mind over and over again, their faces pop out at me usually when I am already upset about something else that is unrelated. 

See? You suck, you suck, you suck! 

Why does our brain do that to us? Kick us when we are down?

Sometimes it is hard in the aftermath of a “mistake” to clear the mind and keep focused. There are other patients to see, my family to take care of. Still, I also need time to grieve and process. To forgive myself. To forgive others. I need people around me, my family, to let me do that without trying to “fix” me. Eventually my mind will settle down and move on.

Because life goes on.

It always does.

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123 thoughts on “A Mistaken Identity 

  1. Being up front and honest about medical mistakes is the best–not to mention the most ethical–way to deal with it. I’m surprised they left the practice with that much longevity, especially since it wouldn’t cause harm. That’s a lot of trust to throw away. But if they weren’t comfortable staying there, then I suppose it was for the best they left. It would be difficult for both sides to interact if their trust was gone.

    Liked by 2 people

  2. Ooh. I don’t know what I would do. With my old doctor, I’d have likely stayed on (all of us.) Now, probably not. Trust is the thing in these matters. You handled it right, though and so did your assistant.

    Liked by 1 person

  3. If my doctor or a person on their staff, made a mistake and told me upfront and honestly, I would be MORE inclined to stay with that doctor since I would know I could totally trust them to be truthful. As long as it didn’t involve that person being drunk, or hungover or in any other way impaired, we as patients need to realize that mistakes happen. Doctors are not machines. I think we as patients need to question all medications, tests, shots, etc. because ultimately we should be aware of the reasons we are having the aforementioned things done. Keep on top of your own health choices, is my mantra!
    I am so glad that you will be able to get over this eventually as it was not your fault and hopefully no harm was done (sorry, I am a staunch anti-vaxxer).
    So if you or your staff learned something valuable from this then all is not lost.
    I would be your patient in a heartbeat!

    Liked by 1 person

  4. Although the right/ethical thing to was to call them, Im sure it wasnt an easy thing to do. Not every doctor would make that call. So good for you! Im sorry they have moved on. I know you understand it intellectually, but emotionally, Im imagining some hurt. A very tough part of your practice when that happens Im sure, because you obviously care about your patients. Be kind to yourself! ❤️

    Liked by 2 people

  5. It always does it goes on indeed!
    It’s correct to say and do to forgive yourself and forgive others and to acknowledge that we are all the same – doctor or what, are not infalliable. We all make mistake and learn from it.

    Liked by 1 person

  6. During an endoscopic biopsy of my wife’s pancreas her duodenum was accidentally perforated requiring emergency surgery. The physician performing the biopsy was forthright and took full responsibility for the mistake. Even though it caused her much misery and a week in the hospital we did not hold it against him. He came by to visit every day, and since the biopsy turned out to be positive for pancreatic cancer he helped put us in contact with oncologists and surgeons for her care. We loved this doctor and would go back to him in a heartbeat if we needed his services.

    Liked by 3 people

  7. I’m surprised they felt the need to leave. It was a very long term relationship, and an error that could have been swept under the rug, but wasn’t. The ‘wasn’t’ part is critical. When someone owns up to a mistake with me, it has huge weight because so many people today are unwilling to be accountable.
    Mistakes happen, and in my opinion, it’s how the mistake is handled that matters more to me in customer/patient service. If you hadn’t told them, and they later found out, THEN trust is lost.

    Sad. I understand why you are grieving.

    Liked by 3 people

    • Errors are very hard for some when it comes to medical care. We all want the appearance of 100% perfection. It is what we strive for. There are certain things that affect patient response, too, their history. There was a lot of struggle to have this baby so I am sure that affected things.

      Liked by 1 person

  8. I know you will put this is the right perspective in time, but still I imagine this is causing you a lot of grief. Our jobs in health care set up this terrible guilt for making a mistake that is only human error. Not intentional, just a mistake. And the mistake was actually the MA’s not yours right? I bet she won’t do that again and pay attention to orders better. So there’s some good out of it.
    Your integrity is more important and in time the family may see that. If not, nothing you can do. But you have to close your eyes at night and so ignoring it was not a choice. I teach our clinicians “do the right thing, all the time.”
    ((((hug))))

    Liked by 1 person

  9. Thankfully, as you said, an error not life threatening but an error all the same. We’ve all made them and it is how we correct ourselves and go on that establishes us, you, others as great healthcare providers who continue to go back day after day and give of yourselves. I was in the laboratory medicine field for many years and I saw errors there, on the floor, practically at all levels. This is not what anyone wants to read, I know. But again it happens-we are all human. And how you handled your specific situation Victo was exactly the right way because can you imagine had you not? How could you live with THAT internal dialogue? It would be worse than any other you may have about past second guesses or coulda, woulda, shoulda. Scarier still, we know there are professionals who will make a mistake, without hesitation NOT say a word and sleep well that evening.

    Liked by 1 person

    • If we don’t acknowledge the mistake happened and make changes to address that fact and prevent it, it opens up the door for future mistakes, perhaps bigger and more deadly mistakes. That is what we want to prevent at all costs even if it wounds our pride.

      Liked by 1 person

  10. My hat goes off.to you again! Mistakes happen unfortunarely! You handled it perfectly I would say by making the phone call. I am sorry they left. Now tell your MA to stop kicking herself. You stop as well!
    Tomorrow is another day, a fresh slate. 🙂

    Liked by 1 person

  11. As you said, not a life-threatening error, but one all the same. You did exactly right by your parent, your patient. You wrote so well about the internal dialogues you and any of us has when things go wrong and how they seem to pop up exponentially just when you don’t need it. There is a much scarrier scenario that exists and this is where the professional commits an error, without hesitation does NOT admit any wrong doing, and then never looks back. Which ego would you rather live with? And had I been this parent don’t know what I would have done in this case so I cannot judge…would not judge. As always a great post to get conversations happening.

    Liked by 1 person

  12. The responsibility of doctors is big, for sure… they deal with life, every single day… And I guess a mistake could be a burden for many of them… Even more if they are truly good doctors.
    A mistake or distraction could be fatal. Luckily this was not the case. I admire all doctors for being able to carry such responsabilities in a proffesional way. I wouldn´t be able to do it.
    Great reading, here, Victo. Have a great day. ⭐

    Liked by 2 people

  13. Hi I too have beaten myself over med error or things that I eventually regret. But the negative perception does not change what have happened. It will only continue to haunt you. I have to learn to see how to use the energy thAt has consumed me and change into inspiration for positive difference. Hope you will heal soon.

    Liked by 1 person

  14. I think you absolutely made the right decision in telling the parents. As I’m pretty sure you’ve read about my son breaking his knee back in November while doing pull ups in the dorm doorframe, he had his big surgery first where they put the six pieces of his knee back together with wires. We had to drive our son Sam to and from his university and to and from appointments and around to classes because his leg was stuck out straight for six weeks. When he finally was able to drive again and start looking toward the future the plan was for him to have his second surgery and remove some or all of the wires that were probably keeping his leg from bending and remove scar tissue and manipulate the leg to get it bending. We were excited about that surgery and Sam was ready to have a regular bendable knee. The second surgery came around and being optimistic the doctor had told Sam that he could go ahead and start PT the next day. During the surgery to remove the wires while he was asleep the doctor was manipulating the leg and trying to get it to bend as far as it could. The doctor got Sam’s knee bent to 130° and got a little overzealous and went for more when he heard a pop. When he came out to tell us how the surgery had gone this poor wonderful doctor looked like a whipped puppy. He didn’t try to sugarcoat it he just told us exactly what happened. He took full responsibility for this situation which meant Sam would not be starting PT and he would be almost starting over with a straight leg again for six more weeks. Sam took it so well, how could we not? This same doctor had worked with me on my own problems after I fell off a horse onto my knees. So a doctor sent me to him for surgery. Sam’s future doctor told me that he would be happy to take my money but that he thought surgery was premature and that I should give my knees time to heal from the fall. He told me it takes lots of time for such healing. I respected him so much for not doing unnecessary surgery on me that I was happy for him to be my son’s surgeon when the time came. Thanks to his honesty in two different situations I would not hesitate to recommend this doctor to anyone and I would certainly go back to him due to his skills and his integrity. So again I say you made the wise choice. Good for you.

    Liked by 1 person

  15. I have chills reading this, and here’s why.

    On my way home tonight I heard a commercial about medical error (from a law firm…go figure). It told a story of a doctor who left something in a patient that caused an infection and death. The cause of death was simply listed as infection. The truth was discovered in an autopsy. How unethical, true story or not. Let’s let one thing be known. Your practice is not that kind of practice. Your assistant and you acted with the utmost integrity. You represent your profession in a stellar manner.

    That inner hate voice is difficult to calm. Please try to show yourself the same compassion that you would show your patients.

    Hugs to you.

    Liked by 1 person

    • Thank you. I think it might frighten people to know exactly how often medical error happens. I served for a time on the hospital’s review board. Man, that will really open your eyes.

      Like

  16. People are so scared about vaccines these days, I’m sure that added to the reaction.

    All you can do is own up to your errors and/or accept responsibility for those made by your staff, which you did. You cannot predict anything else, except perhaps how bad you’d feel if you didn’t tell the parents.

    Liked by 2 people

  17. I think it must take a lot of courage to work as a doctor. Mistakes are almost inevitable. It requires wisdom too–which I think accompanies perspective, a rich sense of “the bigger picture.” I won’t ask how you acquired all that, Dr. V., but I’m guessing that it’s not there in med school. Confidence, sure, and a delight in challenges. But courage and wisdom are not learned in school. And since they clearly present in your writing, it must be that good doctors develop as they go, facing each encounter with all their resources (which include honesty and humility along with knowledge and skill). You give me so much reason to be hopeful about the issue of healtcare. Carry on!

    Liked by 1 person

  18. As I wind down my clinical surgical practice-I don’t do high-risk procedures now- I find myself thinking about my major mistakes, mostly on my early morning jogs. My mistakes are part of my meditation and my humanness though some have resulted in significant consequences for my patients. In short, a mistake as a surgeon is life-changing because once a structure is cut, it’s never the same.

    I haven’t had anything result in death, loss of a limb or loss of a sense but have nicked a ureter, had grafts leak and missed a diagnosis but later caught my mistake. I take full responsibility for my mistakes and pray that I don’t have any more but I know that I will.

    I always try to provide the best medicine that I can within the resources that I have. I can only do what I can when I can. Long ago, I stopped asking myself to be a Superwoman Surgeon. I genuinely care for each of my patients, strive to improve my practice and learn everything that I can for the health of my patients. I am honored to do this but mistakes come with this job and I live with them the same as my patients live with them.

    Liked by 2 people

  19. I’d be truly appreciative if a Dr. ever admitted they made a mistake. To me that would build my trust in them because I would know they have my best interests at heart and they’re not to proud to admit a mistake. I’m sorry that patient left. I’m sorry it hurt. I get why she left too but I’m sorry it went that way.

    Liked by 2 people

  20. Sorry you had to go through this. I’ve been through similar situations when I was practicing law. I told myself then that the fact that I cared so much made me better at my practice. I’m sure that’s true in your case.

    Liked by 1 person

  21. You could not have handled that any better! Sometimes we just need to step away from our own disappointments, and then from the outside looking in, see all of the good we’ve actually done, things we’ve accomplished, people we’ve helped (I’m not a Dr mind you), and realize YES mistakes are made. Learn from them, accept defeat, but then you have to let them go… The first step was here. Writing it down. It’s therapeutic to get our thoughts out on paper (phone/computer), especially the damaging ones. Holding on will only allow it to fester and grow, thus causing you to lose yourself in that mistake, and becoming what you think another may see in you. You are not “your mistake!” We cannot see all, nor can we take back what is already done. But you will feel better knowing, that you ultimately did the right thing, no matter the cost, and you should sleep well… you haven’t lost your integrity, you are simply human. And the same goes for your staff member. No one is perfect… NO ONE! You/they will do better next time, of that I’m certain. Positive thoughts, healthy mind 💜 MJ

    Liked by 1 person

  22. Everyone makes mistakes, and doctors are no exception. Their mistakes just take on more weight because of the possible consequences. I admire you for making that call. Most people, in all professions, will never admit error (just look at our government). It’s a lot of pressure to have to be perfect. (K)

    Liked by 1 person

  23. One of the things I so love about working on my team is how mistakes are handled. They’re treated as inevitable, us all being human, and as learning opportunities. If the same errors come up more than once or twice, then it becomes a different matter … but for those one-offs, there’s so much grace in the response.

    I think this more than anything has changed me the last couple of years, toward being more open about making mistakes and feeling far, far less wretched when they occur. It was actually a work-friend convo that inspired “grace,” and suddenly illuminated for me how few people have spaces where (most) mistakes are no big deal. I am very, very lucky to have a what I do, for however long I have it, which means it’s important for me to start paying it forward as I’ve had it paid to me.

    I don’t know what it’s like to make such a mistake as a doctor, or have it made by one of your staff. I do know that I now see my doctors as human, and trust them to do the best they can with what they have any given moment. I’ll question them and actively engage to validate as much as I can with my limited knowledge … but know they’re human, with all the wonder AND all the mistakes that entails.

    I’m sorry you lost that whole family. But I think you’re freakin’ awesome, and a few totally human errors along the way doesn’t change that.

    Liked by 1 person

    • Thank you! The part about grace brings up an excellent point. When something like this happens how to address it with the staff member who did it? Do you take someone who has been a star employee and punish them? Punishment is what patients want if there is an error. If there is harm done, doubly so. In this case we reported the incident to the system but there was no formal discipline. It is on her record. If it occurs again, we have a problem, but I am not going to fire her because of a single isolated incident.

      Liked by 1 person

      • In my team, the approach is to ask what happened and what steps have been/will be taken to ensure no repeat. If there’s no repeat, nothing more is spoken of it. This helps create an environment that’s really rad to work in, with a strong sense of responsibility in its folks.

        Shortly after I wrote this, I found a one-word mistake in an email I sent a week ago. The one missing word would have made a huge difference if I didn’t reply with context. I forwarded the email to my managers with a note how it made a PERFECT case for another point I’ve been trying to make, and drove home a little on-edge, but so, so glad to work where I do, knowing that I don’t need to be on edge (where so many more mistakes happen!). I think I’d have been a bit more agitated had I not *just* commented on this. 😀

        Liked by 1 person

  24. I used to make mistakes in business and it cost us money, not nearly as important as health. I don’t envy the great responsibility that you bear. None of us are perfect. We can only do our very best with the purest intent and that has to be good enough. I love it that you take your work to heart, are honest with your patients, and keep doing your valuable work.

    Liked by 1 person

  25. From working in the medical field, after a mishap of the wrong medication does given we instilled a new process…anyone drawing up medication in a syringe, needed a second nurse to comply with the drug, and dosage….just a little precautionary step…after we had to have 2 nurses to sign off on disposing of medication, why not giving it….I get to take the credit for this one, I was part of the compliance team…sure it takes a couple minutes longer but the medical errors went down….yay…just a thought….after all were only human….might as well give us the best fighting chance we can…kat

    Liked by 1 person

  26. Hi!
    I read this couple of days ago and have been thinking about it ever since. ‘Trust is gone’ kind of got stuck to my head. I think even though trust was gone because of that incident, respect and dignity was retained because of the high road you took. Even though they left the practice now, years down the road when they’ll remember you it would be accompanied by respectful feelings and not bitterness or betrayal.

    Liked by 1 person

  27. This post is classic, so you. The humility, the humanity. Having said that, your staff (unfortunately, times like this) represents your practice (and you) and the sheer fact of this kind of error makes me want to clap my hand over the mouth of my evil twin. This is why she has kept her family far from MDs and hospitals, and used a(n incredible) midwife for her home birth and postpartum care. Again, I appreciate the honesty here and on that phone you picked up.

    Liked by 1 person

    • The next day I had three patients each tell me that I had saved their lives. That helped. I am no better than a midwife or you when it comes to errors. We are all human. But it is gratifying to know that I am helping others in spite of it all.

      Like

      • It’s your conscientiousness I value and the way you see your patients as people. Tragically, two things that tend to be missing in the world of health care. And even for the old mistakes you run in your head, you don’t suck. Neither was this botch-up your fault. I’m glad you as a parent can understand why that family left.

        Liked by 1 person

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