Responsibilities for monitoring and maintaining quality of care - mistakes

A 14-week-old infant is brought to the emergency department at 3 a.m. by his mother, who explains that he has been irritable all night and not sleeping well. On exam, the patient has a temperature of 37.9°C.

He is irritable while being examined but is comforted by his mother. He has a good cry and suck. Exam is otherwise unremarkable.

The physician reassures the mother that the child is fine and releases the child to go home. Three hours later, the mother returns with the child who has had a seizure.

His temperature is now 39.5°C. Further tests reveal that the patient has meningitis. Should the physician have performed these tests when the child was brought in originally?

Comment: The diagnosis of meningitis can be very difficult in young infants. Some phy­sicians advocate doing a spinal tap on all infants less than three months old who are irritable or have a fever.

However, because the spinal tap is an invasive procedure which has very rare — but serious — complications, many emergency physicians and pediatricians rely on the clinical exam to determine whether or not one is necessary.

A three-hour delay in diagnosis and initiation of treatment for meningitis can have serious negative consequences for the development of this child, and it may even mean neurological damage (which could have been prevented had the diagnosis been made earlier.)

This case raises a number of problems. First, how does the emergency physician deal with mistakes he will inevitably make? By necessity, he is making rapid, critical decisions often based on limited data.

Often, he does not have the time and luxury to call in numerous consultants, do sophisticated diagnostic tests, or even refer to the medical literature. He will inevitably make mistakes.

How can he deal with this situation? How will this affect his practice in the future? Should he vow never to miss another case of meningitis, become very conservative, and do hundreds of needless spinal taps? Should he ignore his clinical judgment?

Will the legal personnel (the hospital lawyers and risk management personnel) help or interfere with his ability to deal with his problems?

How can he learn from this situation in order to maintain his confidence, the respect of his colleagues, and the ability to deal objectively with similar problems in the future?

Another problem illustrated by this case concerns the medical care system in general. Mistakes are an inevitable part of our medical care system.

Common methods of dealing with this include:

(a) the physician attends a morbidity and mortality con­ference (this is a conference among physicians in which they bring up their mistakes; although many of the physicians at the conference are supportive and admit that they might have done the same thing in that circumstance, others may be quite vituperative);

(b) the physician ignores the mistake and hopes no legal action is brought;

(c) the physician attempts to justify the mistake by defending the clinical action;

(d) supervisors and committees audit the performance of health care personnel;

(e) patients bring malpractice suits;

(f) patients make complaints to county and state boards of medical examiners or hospital administrations.

Are these methods of dealing with mistakes effective? Are they fair to all involved? How should we monitor and insure a high quality of care?


In this case, the emergency physician has made a mistake, and as a result, initiation of treatment for meningitis has been delayed for three hours. Unfortunately, a delay of “only” three hours is not unimportant, for now there is a significantly higher probability of neurological damage to the infant.

What are we to think about this? Should the physician blame himself? Should he now contemplate changing his methods so that this will not happen again?


As often happens, we must begin by making a distinction. Our understanding of this type of situation is apt to be confused unless we distinguish two ways in which a physician might be mistaken.

There are two general kinds of “mistakes,” and we should respond to them very differently.

The first kind of mistake occurs when a physician has failed in some way.

Perhaps he was not sufficiently alert and failed to notice a vital bit of information without which he could not make a sound decision, or perhaps he was ignorant of some important medical idea he should have known about, or perhaps he had not gotten enough sleep and so has made a careless error in judgment.

Errors of this type might be called “avoidable” mistakes; to the extent that one makes such errors, one is not functioning as a good doctor should function.

The second kind of mistake occurs not as a result of any failure on the part of medical personnel but as the inevitable consequence of our imperfect knowledge and the imperfect circumstances in which medicine must be practiced.

Especially in an emergency department, decisions must often be made quickly, without time for leisurely consultations, tests, and so forth.

But even when there is enough time, another problem arises: Physicians often must deal with conditions about which not enough is known to ensure accurate diagnosis and treatment.

Mistakes that occur because of such factors may be called “unavoidable” errors; such mistakes will occur when the physician is functioning exactly as he should function, given the inescapable limitations of his cir­cumstances.


Now, with this distinction in mind, we may ask: How is the emergency room physician to deal with the mistakes he inevitably will make? We are asking how it is reasonable for him to respond.

Of course, it may be difficult to respond reasonably, even if one knows what is reasonable, because of emotional stress, our tendency to lay blame when things have gone wrong, and our natural desire to avoid trouble.

A physician who fears that a baby may have just suffered irreparable brain damage because a spinal tap was not done may find it difficult to take an objective view of the matter. Nevertheless, it is worth asking how he should respond if a reasonable response can be managed.

How he should respond depends on whether his mistake was avoidable or una­voidable. If the mistake was avoidable, it may be appropriate that he feel guilty about it.

He has, after all, chosen to work in a field where the cost of incompetence is measured in lives; and so he has accepted a particularly serious responsibility not to foul things up.

When a mistake is clearly his fault, and its consequences are grievous, the recognition of this fact will inevitably be painful and may have other adverse consequences for the physician.

There may be no way to avoid this, short of denying responsibility for one’s actions. And, unpleasant as the prospect might be, in serious cases there may be no good reason why the injured parties should not be able to recover through malpractice claims.

At the same time, we must maintain a healthy appreciation of the fact that no one is perfect, and this means, among other things, that every physician is liable at one time or another to make an avoidable mistake.

Avoidable mistakes are like unforced errors in tennis; even the best players make them once in a while. A good player is not one who never makes an unforced error but is one who doesn’t make them too often.

The appropriate response, therefore, is not for the physician who had made such a mistake to be paralyzed by guilt, or by the fear of further mistakes, but to analyze why such errors are made and to take steps to minimize them in the future.

Morbidity and mortality conferences may be useful in this regard, so long as they do not degenerate into sessions of needless self-justification or assignment of blame.

The physician’s self-respect and his relations with his colleagues can surely survive the admission that he is not perfect (unless, that is, his colleagues foolishly think that they are perfect). His relations with his patients, however, is a more difficult matter.

Patients want perfect doctors; there may be little to do about this except to hope that patients become more reasonable in their expectations.

But an altogether different response is appropriate when the mistake is unavoidable. Self-reproach is not appropriate unless the mistake is somehow one’s fault.

Therefore, if the mistake was unavoidable, there is no reason for the physician to feel guilty at all.

If he has been following the best available procedures, based on the best available knowledge, and yet some patients are not well-served by those procedures, the only reasonable response is to hope that future developments will lead to improvements in what he can offer patients and to try to contribute to those developments insofar as he is capable.

Feelings of personal blameworthiness, together with any statements made or actions taken because of such feelings, are out of place.


In this case, was the physician’s mistake avoidable or unavoidable? Superficially, it might seem that the mistake was avoidable, because the meningitis could have been detected by a spinal tap.

That, however, is too hasty a conclusion. We have to consider the two policies that an emergency physician might adopt:

  1. Order spinal taps for every infant with this infant’s symptoms.
  2. Do not order spinal taps in such cases.

The question is which policy is best, considering what we know about both the benefits and the costs of each.

If policy A is better, the mistake was avoidable. But if policy В is equally good, the mistake was unavoidable, despite the fact that the policy did not serve this particular infant well.

So, what are the costs and benefits of each policy? As for policy A, if spinal taps are routinely performed, at least some cases of meningitis will be detected earlier than they otherwise would have been detected — and there is no safer, more reliable means available of diagnosing it.

The percentage of cases in which meningitis is present will be small, but the disease is so serious that this benefit is quite important.

On the other hand, because there will be relatively few cases of meningitis, hundreds of “needless” spinal taps will also be given, and in at least some of those cases there will be serious complications.

(It should be added, however, that such complications are so rare that some states, Texas for example, consider spinal taps no more dangerous than drawing blood and do not even require special consent for the procedure.)

The costs and benefits of policy В are exactly the opposite. Omitting the spinal tap avoids the risks of needless complications but also forfeits the benefit of early diagnosis of meningitis.

It may also be said, in favor of policy B, that visits to the emergency department are less costly and less traumatic for most patients.

Which policy, therefore, is best? As a layman, I cannot make a confident judgment. This is a matter for the medical experts to decide.

However, I can offer an observation or two about the situation we are in when the experts disagree, as they apparently do in this matter.

First, we should avoid the mistake of thinking that there must be one “correct” answer to the question of which policy is best. It might very well be that neither policy is better than the other.

The pros and cons of the competing policies might add up in such a way that the result is a tie or, at least, so nearly a tie that conscientious physicians cannot be brought to agree.

As a layman, I tend to think that when equally well – informed and conscientious experts cannot agree on a matter like this, it probably is a tie. In that case, there will be no definitive answer to the question of which policy you should adopt.

Indeed, it might turn out to be a good thing for both policies to be adopted in different emergency departments, so that we gain the additional experience of both.

We should also avoid the mistake of thinking that there will always be an easy calculation that would “answer” such questions, if only we were clever enough to figure it out.

Practical judgment often requires balancing considerations that are not quan­tifiable — exactly how much increased risk is justified, for example, to make emergency department visits less costly and traumatic for most patients?

In dealing with such matters, the element of reasonable judgment may not be eliminable. But this only underscores the extent to which disagreement among “reasonable physicians” might be unresolvable.


In the particular case we are considering, I conclude that the physician’s “mistake” was unavoidable. He was following a policy that, on balance, seems to have been at least equally as good as the alternative.

Therefore, it would not be appropriate for him to feel personally responsible or guilty for the tragic situation of the undetected meningitis.

If his self-confidence is diminished, or if complaints about his handling of the case are forthcoming, that is to be regretted, just as the infant’s tragedy itself is to be regretted.

He should deal with this mistake, not as a particular error of his own, but more im­personally, as an unfortunate limitation of medical practice in its present imperfect state.

There are not only medical errors; there are also errors of moral reasoning. Errors of moral reasoning have their own distinctive costs.

In this case, if we err by overlooking the difference between the two kinds of mistake, that is, if we respond to an unavoidable mistake as though it were avoidable, the costs are fairly high.

The physician may torment himself needlessly and may even contemplate major policy changes that are entirely unnecessary. This is a case where moral philosophy can help, by relieving the physician of these worries.