Reflection on medical errors: A thematic analysis

Figures & data

Figure 1. Cover Book ‘When healthcare hurts’.

Table 1. Illustration of how the reflection themes were derived from the coded data by posing specific questions.

	Specific questions to identify the trigger, topic, lesson learnt	Coded data	Searching for verbs and nouns to identify themes	Theme
Trigger	How did the doctor recognize that something was wrong?	‘A few months later, I received a four page letter from this couple telling me that their baby had died’.	Received …letter Telling … died	Death
Topic	Was there an analysis and explanation by the doctor of what had happened?	‘Her trip to India had blinded me to other possibilities and her symptoms had nothing to do with her visit to the tropics’.	Trip …had blinded Had … to do .. tropics	Trip had blinded me
Lesson learnt	What kind of lesson did the doctor learn, visible in the behavioural changes, after making the error?	‘These incidents have made me more aware of my intuitions, and taught me not to be distracted by other people’s emotions’.	Aware … intuition	Awareness about intuition

Table 2. Illustrative quotes of triggers which made the 12 doctors aware of their error.

Trigger (n)	Illustrative quotes
Death (n = 9)	‘I realized that as a result of my ineptitude, I had caused the man a urosepsis; he died that same evening’.
Complication of an intervention (n = 4)	‘Two days later I received a phone call from a plastic surgeon. The boy had been admitted to hospital with a serious infection of the skin on and around the penis. ‘
No explicit trigger mentioned (n = 3)	‘As soon as the sedative had been injected, I realized my mistake, almost a sixth sense’.

Figure 2. Topic themes in the doctors’ reflection reports - 41 of the 12 doctors’ quotes summarized into 20 themes belonging to the outer and inner world.

Table 3. A selection of illustrative quotes related to the topics’ themes mentioned by the 12 studied doctors.

Topic themes	N	ID	O/I	Illustrative quotes
Went along with patient’s explanation	4	4	I	‘I did allow myself to be guided by the patient though, by his own dissimulation. He had made light of his symptoms, unlike his wife, who told me she had never seen her husband like that before’.
Gut feeling	4	11	I	‘We had inserted the device, I was not completely sure if it was in the right position. I don’t know why I hesitated; it was a gut-feeling’.
Insufficient knowledge and skills	4	10	I	‘I had to make a decision I wasn’t sure about because I knew too little’.
Confirmation bias	3	12	I	‘I had succumbed to that well-known pitfall whereby doctors tend to look for explanations and symptoms that confirm their own hypotheses’.
Organisational stress	3	1	O	‘When I called the cardiologist about this first patient, the response appeared disturbed. As a department we should get our act together because due to our planning we were seriously disrupt the outpatient clinic’s schedule’.

N: number of times the topics were mentioned by the 12 doctors; ID: doctor’s identification number (1-12); O/I: outer world/inner world.

Figure 3. Lessons learnt themes in the doctors’ reflection reports - 58 quotes by the 12 doctors summarized into 16 lessons learnt themes belonging to the outer and inner world.

Table 4. A selection of illustrative quotes related to the lessons learnt themes mentioned by the 12 studied doctors.

Lessons learnt themes	N	ID	O/I	Illustrative quotes
Openness and fairness among specialists	9	4	I	‘Fortunately doctors these days are more open than they used to be, and I come across far less silence and arrogance than I used to. A reticent, arrogant attitude is the worst thing you can have when something has gone wrong. There should be far more openness these days among doctors about their mistakes, be they minor, major or potentially catastrophic in nature. That helps doctors to cope after an incident. Moreover, colleagues can learn from your mistakes and that makes healthcare safer’.
Giving an account of actions	7	8	I	‘Despite the protocol, the affected eye had not been marked. You raise the matter with the person responsible, of course, but you also have to take a critical look at your own role. Why did I not raise the alarm as soon as I realized the eye was not marked? Why did I carry on that moment? Why did I consequently check the patient’s notes extra carefully?’
Teaching	4	3	O	‘For the last three years, as part of this approach, I have been giving lectures about my own medical errors’.
	2	5	I	‘Slowly but surely, it has made me aware of the fact that we have to change social conventions in our profession if we want to make health care safer for patients. As a clinical teacher and professor of medical education, I consider the official curriculum with regard to patient safety less important that what we in educational terms refer to as the ‘hidden curriculum’, in which you learn about social norms, those unwritten rules that determine what you do and do not do. You have to find a way of influencing that hidden curriculum favourably in order to change the culture and increase patient safety. It is a quest in which clinical educators play a crucial role, for example, by teaching and showing new generations of doctors what is meant by accountability’.
Acknowledgement about the relevance of collaboration	5	10	I	‘It is one of the reasons why all interventions here are carried out by two people, so you can make decisions together, and it forces you to discuss things’.
Writing and publishing about mistakes	3	3	O	‘The article was accepted by the internationally renowned Journal Surgical Endoscopy and published in 1995. The patient kept her word and, to my surprise, I received many positive responses from leading medical centres abroad as a result of my openness’.

N: number of times the lessons learnt theme was mentioned by the 12 doctors; ID: doctor’s identification number (1-12); O/I: outer world/inner world.