Ryan Fitzgerald, DPM PRESENT RI Associate Editor Hess Orthopedics & Sports Medicine Harrisonburg, Virginia

In tonight’s Residency Insight, I’d like to broach a subject that many of us seek to avoid as vigorously as possible –the idea of medical error. These errors need not be a “Wrong-site” surgery type errors. This type of error always seems to get the lion’s share of the press. Indeed, medical errors can exist in places you might not otherwise expect. None of us is perfect, and consequently, we will all make our share of mistakes throughout our varied careers. Despite this, many errors can be avoided if we make a conscious effort to critically evaluate our performance and seek out areas that may predispose us for error. Certainly, medical errors will be far easier to prevent if we are actively and routinely evaluating ourselves in an attempt to minimize this risk.

Commonly, medical errors do not occur in isolation, but rather they occur following a chain of events that lead to the error . Many of you who know me personally know that I am a pilot, and in aviation, there is a concept known as the “error chain,” which is a term referring to the concept that many contributing factors typically lead to an accident, rather than one single event. These contributing actions typically stem from human factor-related mistakes and pilot error, rather than mechanical failure. Indeed, many aviation incidents can be attributed to a chain of errors that, had any link in the chain been addressed, the catastrophe might have been averted. During flight training, student pilots are taught to critically evaluate their performance and be aware of the potential “chain of error” and how to avoid falling prey to these avoidable events. Our training as physicans and surgeons is no different.

Among the skills you must learn as part of your residency training, risk management and critical self-evaluation are just as important as learning to do an excellent bunion or a triple arthrodesis. We must learn to identify those avoidable pitfalls that may serve as precipitating events in a chain of error which can lead to a significant medical error. You need to be you own greatest critic, and following each surgery or patient encounter, you should make an attempt to evaluate you performance –“What did I do well? What could I have done better?” In doing so, you can continue to push yourself to perfect your craft. Your patients deserve the very best “You” you can give them.

Finding oneself in the chain of errors is like being in quicksand –it slowly sucks you in and you don’t realize you’re there until it is too late to get out. The best way to avoid a major error is to recognize the systems-problems and human factors that may propel you into that avoidable chain of error. You can’t see the quicksand unless you’re looking for it.

We at PRESENT love hearing from you. I would challenge you to share some of your successes (and perhaps some of your failures) in avoiding the quicksand in your practice. Follow this link to view an eTalk on the subjection of medical errors.

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