M&M last week was scary. Scary as in, I don’t let myself say, I would never have made that obvious of a mistake. Instead I say, someday I will be the one to make that mistake, so I better watch out.
No details at all, just the lessons I got:
Never believe anyone. Verify everything for yourself. Seriously, not just an axiom.
Look at all xrays as a matter of course. In addition, I must personally look at every CT done on every patient I’m caring for (let’s say done within the last week), regardless of whether radiology has read it, and regardless of whether other surgeons have told me it’s ok.
Every CT, slowly, head to toe. Then on lung windows, head to toe again, slowly (this is a different penetration view of the CT, to show lung findings, abdominal findings in a new light, and check for free air).
If a patient feels like they’re doing badly, start from scratch and look through the whole story again for yourself.
I’ve gotten through the first week of nights without any major disasters. That isn’t a good thing; that means they’re still out there, waiting for me. . .
Of course that isn’t true – on another level. Of course I said I’ll never be the one to make that awful of a mistake. It’s a game of roulette: if I concentrate hard enough, maybe I can make it through; as though will-power can bend chance, or concentration will never fail. . . but if we didn’t all think there was a chance we could try hard enough to not make the mistakes, we would have to stop right now.