I just heard Scott Weingart’s new podcast about errors of omission compared to errors of commission.   The podcast was inspired by a patient with aortic dissection and hemopericardium who arrested and died, without any attempt made to drain the pericardium.   This raised the question of whether our culture of “do no harm” has led us to fear errors of commission to such an extent that we are paralyzed to act in emergent situations.  

Balancing errors of omission and commission is tricky.   I have seen similar errors of omission in pericardial tamponade where there was a failure to act due to hesitancy of a non-cardiologist to drain the pericardium.   On the other hand, I’ve also seen many errors of commission when unnecessary procedures were performed emergently under suboptimal conditions.   Both types of error can be lethal.  

The commission-omission equation is a way to balance errors of omission vs. errors of commission, a calculation which we perform subconsciously.   For patients who are not significantly ill, the focus is on avoiding errors of commission (“first do no harm”).   Such patients aren’t very sick, so there’s little to be gained by aggressive interventions.   As patients become increasingly ill, then the potential benefit of interventions increases and it is sensible to treat more aggressively while accepting more errors of commission.   The extreme situation would be a patient who is coding, a situation where there is little to be lost so the focus is on avoiding errors of omission – anything that might work should be tried.  

Problems arise when clinicians get accustomed to working at one part of the commission-omission equation and fail to adapt to the situation properly.   For example, internal medicine physicians are often used to working on the lower acuity end (“do no harm”), so it may be challenging to shift to a more aggressive approach when needed.   Conversely, trauma surgeons are more accustomed to the higher acuity end, so there may be a danger of being excessively aggressive when presented with a patient who is not actually critically ill.

Balancing errors of omission with errors of commission is challenging.   Rather than absolutely attempting to avoid one type of error, the best approach may be to adapt the level of aggressiveness to match the patient’s level of instability.   The goal is to minimize the total amount of errors (commission + omission), rather than to avoid one specific type of error (commission or omission).  

Of course, a certain amount of error is unavoidable.   This error should be embraced, studied, and openly discussed.   It must not be misinterpreted as a personal failing of the physician nor swept under the carpet.   Error is our greatest teacher.