My first mistake

This is an essay I wrote a few years ago that was published on Doximity, on online forum for physicians. It's time to dust it off and shine a flashlight again on the truth: doctors are human and they too make mistakes.

I saw my senior resident storming down the hospital corridor towards me. As soon as she was several feet away, she yelled out “You killed your patient!” I looked at her in astonishment. “What are you talking about?” I replied with a rapidly accelerating heart rate. “Mrs. S, the woman with lung cancer. You put down the wrong code status in the computer!” Furious with me, she walked briskly away and I was left standing in shock in a silent empty hallway.

This was just the beginning of one of the most traumatic experiences of my physician training. I had just started my internal medicine rotation as an intern, several short months after graduating from medical school. I had admitted Mrs. S the evening before and though I barely remember the conversation we had regarding her code status, I do remember her telling me this: “When it’s time for me to go, let me go.” Mrs. S had stage 4 lung cancer and we admitted her for treatment of severe pneumonia. I put the orders in the computer and continued to see and admit other sick patients.

At 7 pm I stood in line to give my verbal report to the intern who would cover all of the ward patients overnight. We had a sign out sheet that told the intern the basics about all of our patients. For Mrs. S, I told the intern: “She’s stable, getting IV fluids and antibiotics, oh and by the way, she’s DNR/DNI.” I then went home to try to catch up on sleep, something in short supply as an intern in residency training.

Early the following morning I get report from the bleary-eyed intern, who managed by himself all the constant paging from nursing with overnight emergencies. He ran through my list of patients quickly, briefly mentioning that Mrs. S died. “What? Really?” I said. “Yah, she went into a-fib with RVR, didn’t respond to IV labetalol, got hypoxic, and then died pretty fast.” “Did you talk to her family?” I asked. “Yes, when I knew she wasn’t going to make it, I called them and told them we were doing everything we could to make her comfortable.”

To make her comfortable. It turned out the mistake I made was putting in the code status order as “Comfort measures only” rather than “DNR/DNI.” Because the computer stated comfort measures only, the intern didn’t attempt anything other than one dose of IV labetalol. I have no idea why I clicked on “Comfort measures only” when putting in the admission orders; I either didn’t know the difference between the two or I just clicked on the wrong button. I did not double check my orders.

When our attending arrived that morning and learned of the patient’s death, he just looked at me in silence. In addition to feeling so awful that this woman had died, by herself, without her family present, I felt an immense amount of shame. How could I have gotten this wrong? The case was immediately brought to the attention of the risk department, and the review was led by a pulmonologist. He was so kind in his comments to me after reviewing the case. He told me that I didn’t kill the patient, in his opinion, her oncologist had. She was receiving some late stage chemotherapy treatment that required her to take high dose steroids, which made her immunocompromised, leading to her pneumonia. He also told me that even if her atrial fibrillation had been controlled, her respiratory status would have likely deteriorated, and she didn’t want intubation. It was her time, he told me.

I didn’t feel any comfort by his words. In between seeing patients that day I went to the intern room and sobbed. I had killed a patient. My senior resident was right. I am not fit to be a physician. I should just give up now. The self-degradation went on and on, the shame continued to suffocate me, and I was terrified I would soon make another fatal mistake. The next day the senior resident who had confronted me sat me down to give me a patronizing lecture on the difference between comfort measure only and DNR/DNI. She shared no words of sympathy or empathy towards me. Because I had failed, she had failed, and she was going to punish me.

Gradually, after many months had passed, I was able to look back and think more logically about all the things that lined up to allow this mistake to occur. We had learned in medical school about the swiss cheese model of errors, taken from the aviation industry, where multiple little small mistakes or holes can eventually line up together so that one bad outcome slips through.

Yes, I obviously had a lack of knowledge and a level of fatigue from being overworked. But there were other holes: my senior resident didn’t double check my orders. Isn’t that the standard when supervising a brand-new intern? If the patient was really comfort measures only, then why was she getting IV antibiotics and fluids? Why didn’t the nursing staff question this? Why didn’t the intern call his senior resident for assistance when she went into atrial fibrillation? And why hadn’t the oncologist had an honest discussion with Mrs. S about the realistic prognosis for her advanced lung cancer?

I have used this transformative experience as a way to improve my discussions about code status with my patients. I have also told every single medical student or resident I have worked with in the last 10 years about my first mistake. I do this because physicians don’t talk about their mistakes, either to their patients, or to their colleagues. I do it because making mistakes is part of being human, and even though we are highly trained with the best intentions, the holes line up, mistakes are made, and patients may suffer. I share my story because I am no longer ashamed.