Cite this post as:
Scott Weingart, MD FCCM. Mind of the Resuscitationist – Errors of Commission and Omission. EMCrit Blog. Published on June 6, 2014. Accessed on March 29th 2024. Available at [https://emcrit.org/emcrit/motr-commission-and-omission/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
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Original Release: June 6, 2014
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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So very true in medical education today. Not only true with dramatic procedures such as a pericardiocentesis, but also just the medical management of patients. The tasks we used to give med students we now give interns; the tasks we gave interns now belong to senior residents; so on with fellows, with attendings, then finally to subspecialty services. The only explanation I have found for this ascending responsibility drift is liability; the ominous threat of legal action should there be a complication.
Great topic.
Fix what is killing the patient first.
When I was a resident, I was able to intubate without an attending in the room. Now as an attending, in the current climate, that would be beyond unthinkable if one of my residents intubated while I was elsewhere in the dept.
Well, from my point of view. That is being a resident in Sweden. Most of the time it is easier to be passive than active. And you sadly get in less truble for not doing.
—Mikael Nöjd
yep!
Scott – it is an interesting tension in the scenario you depict. On Omission vs Commission
The junior medics would tend towards the error that “gets them into less trouble” whereas I am sure the patient would prefer the ‘error’ that leaves them with the “best possible outcome”
I fear that the two are not always (or often ) the same thing.
I think that is the crux of the problem here?
Casey
Scott: First off, great topic! Look forward to the responses and further reflection from the greats on here. Wouldn’t let me open the link attached for recommended reading, says I need to have a name and password to your website? Any chance you could post it in another format, maybe a .pdf?
fixed thanks to Tim below
Link to Reason’s paper is here :
http://kidocs.org/wp-content/uploads/2014/06/Qual-Saf-Health-Care-2002-Reason-40-4.pdf
thanks Scott. interesting discussion point. essentially a philosophical challenge. You might have even quoted Hamlet !
I dont think its a binary equation. its not black and white. It depends. and we dont always get it right
Hemingway once famously said “Its better to wade in and get hammered in the process”..he was a serial committer I hazard!
Its really about the philosophy of ” Act and beg forgiveness” vs “First do no harm”
Life teaches us the former, whereas medicine teaches us the latter.
and you are right..its got nothing to do with mental toughness.
absolutely, brother! And it is always better to beg forgiveness than ask permission!
Hi, first time contributor. Very interesting topic. We are trained to “first, do no harm.” This may weigh on our minds as we deliberate performing a procedure or intervention. I know it does mine. “Do” is an action word. If we are taking action and harm occurs, then WE have done harm. If inaction leads to harm, we* do not feel as guilty or as much a participant, even though we decided not to do the procedure. We were not the ones to pull the trigger. Some of us fall into a certain mentality of omission based on that word,… Read more »
just beautiful and now the post has a theme song. Thanks for coming on board Dave!
I thought I would listen to something relaxing before going to bed, but no. O_o I see this the opposite way in EMS. Rather than being afraid to do something that is right, we are afraid to not do something – no matter how harmful that something is. Backboards (beloved of trauma surgeons trying to fit a curved back to a flat piece of rigid plastic and blaming EMS for the problems with this incoherent untested hypotheses) have been used for decades, because “What if we don’t do everything possible to the patient?” It’s Cricolol. Epinephrine for everyone who remains… Read more »
Love the comments Rogue! You and Seth below both mention the issues of over-treatment which is obviously a huge problem in EMS and the hospital. I was not quite touching on that problem so much as the decision to do the hard, big ticket items; the high stakes things. And then you got to EMS protocol violations, and that is the perfect example. Or even in protocol items where you need MedCon, but you can’t get them due to radio issues. Do you give the treatment anyway knowing the pt will get better from it or do nothing b/c you… Read more »
I was not quite touching on that problem so much as the decision to do the hard, big ticket items; the high stakes things. What about the simple big ticket items, such as intubation? Is the tough decision to wait and try something less aggressive or to intubate before the patient becomes unstable? Your discussion of this for DSI is something that is using aggressive intervention with ketamine that may lead to an improvement that would allow for aggressive withholding of intubation that, on further assessment, no longer seems to be in the patient’s best interest. The gold standard of… Read more »
Amen! But then there could be the obvious discussion of the difference between an experienced, astute medic doing this vs. a potentially arrogant rookie–dunning-krugerr, etc.
Currently, some of the doctors have known me for about 20 years. That helps the communication, but I think that newer doctors have become much more willing to listen to paramedics and realize that treatments delivered outside of the hospital can be just as beneficial, or harmful, as treatments delivered inside the hospital. There also seems to be more of an understanding that, related to this podcast, that not doing something/ordering that something not be done, can be bad patient care. I think that what has worked in my favor (other than the good fortune of the doctors involved not… Read more »
Awesome topic, and I’m really looking forward to what comes out of it! As a med student, I feel that two things have really helped me start along the path of granting ‘self-permission’. One is educating myself on cognitive biases and human factors (kahneman/judgement in managerial decision making/less wrong sequences/HPMOR). I feel this helps a lot with respect to insight into these situations – identifying cognitive barriers and overcoming them. The second is #FOAMed, encouraging excellence (ie not copping out, an internal mental model where it is simply expected that pericardial effusion+tamponade = time for pericardiocentesis). I feel like a… Read more »
We just need a little Cliff Reid bobble-head that you can put in the resus room that just says, “If you think it-do it. If you can think it-you can do it” on a loop.
OK, this all get’s a bit philosophical – and indeed a bit circular… We do not rise to the level of our expectations. We fall to the level of our training. Archilochus, Greek Soldier-Poet, 650 BC The entire medical system is geared up to criticise mistakes, viz : “Did you hear what those dumb ass docs did in ED? Thank heaven we in ICU were able to save the patient!” “What about those rural docs? You can’t fix stupid!” The problem of course is that often trainees don’t know what they don’t know…and even if they DO know, they may… Read more »
I think we need to train commitment as well as the procedure just as you say
ie : train them in difficult decision-making, not just knowledge-base.
Interesting talk, and clearly there are a lot of times where the bias is toward inaction. On the flip side, our system is clearly biased toward “doing something” on a bigger scale — rigorous workups for low risk chest pain, increasing use of CT, excessive coronary stents, and probably most importantly, the immense over-treatment at the end of life.
I’m not sure where the divide is: overcommit on the big scale, but individuals without permission to act during resuscitation?
The system is geared towards the over-doing of things that are easy; not for the things that are hard.
Great topic. Like others have said, it seems a bit ridiculous to say ‘first do no harm’, even though many seem to make it a mantra for med students like me to live by.
I’d be curious to learn how the med-legal cases on each side of the argument tend to work out. Is care legally deemed inappropriate in cases where X was done and went south more/same/less often vs situations with omissions of active care?
Kyle, see Rick Body’s post linked now in the main post above for a discussion of the silliness of first, do not harm as an excuse
Hi Scott
I wrote a really long reply – the thought…. ahhh bugger it – I’ll just do an audio rant: http://traffic.libsyn.com/broomedocs/Pearl_-_Schizo_mind.mp3
Its all about Kenny rogers really!
Casey
great! i put it in the main post above
you can see this thread has pulled out all the philosophical geeks with rants on the meaning of life , existential despair and medical futility with dashes of EBM religion. May I suggest getting back to reality and the case cited of two junior doctors dealing with a critical patient who eventually died of severe aortic dissection. In all probablity even if a pericardiocentesis was done and successful the patient had a significant risk of dying regardless. To say that these doctors failed to act is a gross assumption. You could equally argue they acted within their scope of practice… Read more »
Yes, it is a matter of opinion. However, not all opinions are equally valid. That is where the evidence, the quality of the evidence, and the application of logic and experience come into play. We should take a skeptical approach to intervention. Medicine has a horrible history of encouraging intervention based on expert opinion, weak evidence, and unwarranted wishful thinking. This time it will be different!. As your tPA example highlights – we haven’t stopped counting the hits and ignoring (or making excuses for) the misses. A success rate of 2/11 is horrible, but that is the evidence for tPA.… Read more »
Rogue, how is this in anyway relevant to the cited case at hand? What opinion is valid when you have someone dying of a pericardial tamponade from an aortic dissection? What would you have done if you were in the position those junior doctors encountered?
I hope that I did not give the impression that I was, in any way, addressing the specifics of this example. The example does not contain many specifics and I did not interpret it as intended to discuss specifics.
I did interpret this case as a presentation of a general concept that is intended to generate an important discussion of the ways that we make decisions.
.
Hi Minh
I would make it clear – I make no criticism of a specific doctor’s decision to act or not act. The problem as I see it is the failure to change gears (up or down) and provide the most appropriate level / degree of aggressive care.
We should train Docs to recognise when they need to switch gears – or else you get inadequate Resus or on the otherside Overdiagnosis and innappropriate care.
C
Thanks Casey. I appreciate your attempt to delineate the problem. I am not sure if you have proposed a solution..or even a list of options towards a solution…or even a hint of a suggestion as to a way possibly remotely forward towards a solution.
I am even uncertain if what you describe is what these junior doctors faced? Do you really think it was a problem with being able to change gears? really?
I think we can over-analyse all this and I don’t think it’s about sins of omission or commission at all. I think it’s about having a supportive environment where people feel able to go out on a limb when necessary and understand that if things do go wrong they will be safe within an honest, no blame culture where such events are learning events, not a means to strike people down and humiliate them. Mental toughness? No, you don’t have to ‘do’ things to your trainees to foster the right spirit, just bring them up in the right overall culture.… Read more »
Obviously I agree with all that except for the mental toughness being a cultural assimilation situation. Yes if we chose to raise our trainees in constant austerity and punishment like the Spartans did, they may become tough by culture alone. The OBGyns in New York seem to have adopted this path. The trainees may be tough in the sense that they are generally mean and bitter, not what we are looking for. The special operations groups of the military also have a culture, but they take specific steps to breed the desired toughness in their recruits as well. David, it… Read more »
Hi Scott, Sorry for not responding earlier, but I’ve been caught up. The term, ‘mental toughness’, doesn’t rankle, but equally I think it’s important to view it in its cultural context, that of US emergency medicine. To this foreigner, the US approach to emergency medicine can sometimes seem to have a bit of the ‘Seal Team Six’ about it: a macho, at times quasi-military air. The question you frame is fine and valid, but perhaps it is also culture-specific and maybe the term ‘mental toughness’ is not appropriate to other EM global cultures. Certainly, I find the concept alien and… Read more »
I think many of us in resuscitation actually wouldn’t mind a mindset comparison to special forces (excepting the macho of course, b/c we need tough women and men). This same attitude can’t be extended to non-critical care EM, just as you mention. Thanks so much for commenting.
Maybe. I’d be interested to see if specialist ‘resuscitationists’ in other countries agreed with you. I suspect the special forces thing is more culture specific than a general phenomenon of ultra-acute emergency medicine which transcends cultural boundaries. Anyway, a moot point. Interesting podcast. Thanks.
“I actually began to believe the problem is actually one of self-granted permission to act” I think you hit the nail on the head here Scott. As trainees we are so used to our consultants/attendings affirming or prompting our decision-making that when we are faced with the need to make an immediate decision to act without them, we can falter at the last step. The other part of it is the little niggle in the back of our minds that says we could be wrong. I know on night shift my thought processes can get a little muddled and it… Read more »
Great podcast, Scott – as usual! I think this is really interesting. Minh, I totally agree with your point about being judgemental and I think it’s really important that you made it. However, to be fair to Scott it would have been hard to make this podcast so interesting without giving it a clinical context – and the story does just that. In the worst scenarios, we all know that we can get into more trouble from acts of commission gone wrong. Look at the cases of doctors convicted of gross negligence manslaughter – they tend to be convicted for… Read more »
thanks Ric! Can you sing all that to a piano tune as well! Python was right all along…”Always look on the bright side of life..” seriously, well done for pointing towards a way forward that has humanistic pragmatism! Enjoy your job, focus on patient needs. I subscribe to that philosophy rather than mechanistic dogma, EBM religion and existential medical despair. Doctors are indoctrinated to fear. we are made to see ourselves as machines,computers, EBM scientists. We are not supersoldiers The art is lost to the science. Humanism is forsaken in the face of an irrepressible enemy, death. so thanks for… Read more »
The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact. – Thomas Henry Huxley.
EBM helps us protect our patients from treatments that do not work.
Using treatments that do not work on our patients expose our patients to risk for no benefit.
EBM is Ethics-Based Medicine as well as Evidence-Based Medicine.
.
Well then it’s ethical to give epi in cardiac arrest as per the two RCT for VSE !
Checkmate
Please explain.
Are you suggesting that all epinephrine in cardiac arrest is effective? A specific cocktail that contained epinephrine as only one of three drugs has been shown to be effective. Are you suggesting that we should look for loopholes and that this is somehow the way EBM works? You finish with – Checkmate I am accustomed to seeing this in comments from vaccine denialists and other science denialists, Is that what you intend? In what way would your comment be a form of checkmate? I know you are capable of explaining much more clearly. I would rather respond to what you… Read more »
Judging by the comments, you’ve obviously struck a nerve here. A wonderful surgeon once told me that a good surgeon knows when to operate, but a great surgeon knows when to NOT operate. Over the last 20 years, I’ve seen as many bad outcomes from omission as I have seen from commission, and wisdom lies in quickly weighing risks and benefits and acting accordingly. It’s a gross and dangerous oversimplification to make blanket statements about whether it is better to err towards action vs inaction. To be sure, the twin crusades for patient safety and resident work reduction have (in… Read more »
agree on both the surgeons comment and the residents–striking the balance has been ridiculously hard in my career as an educator
Thank you RougeMedic for giving me the courage to add my voice to this discussion. As an RN I am not sure that all of my opinions will relate to all of you, but I am a long time listener of the podcast and I have never heard Scott discuss an issue to which I have felt compelled to respond. I agree with you Scott, we are more likely to overDO the easy stuff and omit the hard stuff as a medical culture. Kidocs discusses the training process, including training good decision making, and training to DO and succeed instead… Read more »
love the long response. love that rogue has been rebranded as rouge. I spent the past year back at shock trauma, where the nurses are empowered at every level to call an attending if the fellow is not being maximally aggressive. If the attending doesn’t stand up, they call the physician-in-chief. The right RNs can be masterful guarantors of optimal care.
I am a blushing rogue.
😉
Hahaha. I am going to go ahead and blame the four am post time for that one. Sorry rogue!
Sorry to join the party a bit late….. As a trainee with only 6 months of training to go, I think Kath and Rick probably encapsulate it from where I am. There are times when it is hard to switch into Casey’s “surgical” mode because in the back (and front) of my mind is the subsequent conversation in a law court: – So, Dr C, have you ever done a pericardiocentesis/thoracotomy/perimortem C-section? – Erm, no. – And have you had training in cardiothoracic surgery/obstetrics/any kind of surgery? – Erm, no. – And did you discuss with a consultant before you… Read more »
precisely! And I bet if the consultant called you up and said stick the damn needle in the chest, you’d get it done, no?
Immediately! (As long as I agreed it needed doing…….)
PS – in direct reply to Rick – I AM afraid. Having had my life on hold for 18 months with the Damoclean sword of potential prosecution over my head made me afraid….. and I will probably stay that way. I doubt that I’m unusual in that respect amongst those who have been on the receiving end of the regulatory authorities 🙁
Interesting discussion- but IMO 2 separate discussions. I think “permission to act” is relevant to the case presented, and having a mental model of the procedure may give oneself “pre’ permission” to avoid unnecessary cognitive load when the time comes. Puts me in mind of Cliff Reid’s “Hero” talk and Rich Levitan’s “barriers to cut” in cric discussions. But errors of commission/omission are very different when discussing testing vs. procedures. Extra testing is somehow “safer” and extra procedures are “invasive” and “aggressive.”. So medicolegally folks seem to treat extra testing as “safe” while procedures are “dangerous.” Rewarded for errors of… Read more »
absolutely right, Pik. This dealt purely with treatment, folks consistently err on the side of excess commission when it comes to testing in the US.
Great podcast Scott. A bit on my background before my comments : after a 15-year career in EMS, I’m in the home stretch preparing to go to medical school, with the goal of returning to pre-hospital practice as an EMS Medical Director. The exact topic of this article and podcast plagues me daily as a Paramedic FTO in an urban setting with conservative protocols and a typical transport time of 30 minute transport times, where the paramedics actually get to practice medicine). I see a two part problem here: first, my primary system is one in which every employee gets… Read more »
ETA first paragraph: “my typical transport time is 30 minutes where the medics actually get to practice medicine”. Late night, too much copy and paste…
yes!
hi scott it all depends – in a stable patient i will not do a procedure with a risk of harm unless i am 80 % sure it should be done (pareto analysis 80% rule). as the patient becomes more unstable my 80% starts dropping and i have less concern about potential harm. it also involves knowing what is the right thing vs being unsure as well as having the skill set to do it. all these variables play in my mind. we all make judgement calls that someone will question when things go wrong. in the end, if i… Read more »
it’s a good heuristic. I guess by pure application of Pareto, it would actually be that we should only perform the 20% of treatments that have the most yield; and we would wind up with 80% of the beneficial outcomes. Still like the idea that you need to be 80% sure before acting. It is identical to the treatment threshold lines we use for deciding any intervention.
Where I find the biggest issue is not “do or not do”, it’s “do what is right, right now.” I’ve seen patients harmed by inappropriate medications or therapies in an attempt to “do something”, and then I’ve seen patients harmed by not doing a procedure that they need. So some of it comes just simply to having the knowledge to do the correct treatment. But some of it comes from from the ability, or lack thereof, to decide, and I agree that the medicine vs surgery analogy is very correct in this case. Agree with Casey in that there needs… Read more »
yep
Great podcast, very thought-provoking.
I put up a quick blog about this (http://www.pulmcrit.org/2014/06/errors-of-commission-vs-errors-of.html). I wrote the blog before reading all the comments in efforts to be original. The general concept ended up being similar to Casey Parker’s audio rant although rather than emphasizing distinct mindsets it places things along more of a continuum of aggressiveness vs. level of acuity.
great post!
Great discussion. Grappled with this recently, and after much rumination am now in a place where next time I may l give my self more permission to act. A lot of these decisions live in the grey zone. My recent dilemma was whether to intubate a patient who gave every clue to being a very difficult airway on the floor (literally)in a department across the hall from my ED, or to grab them and run them over to my team and equipment (endtidal CO2,CMAC) which I Believed in that moment to be the best chance of success. had the mental… Read more »
Hi Renee yes I have been in that situation before and yes I regretted moving the patient . having said that I think we will always be at risk of getting burnt by these situations. I dont think moving the patient to a better resus area if it cAn be done quickly is a bad idea. The problem is that it can take longer than we predict and the patient can deteriorate whilst nothing is being done during the move, I have tended now to start resuscitation with basic gear at the bedside and call for help and more gear… Read more »
Renee–there is no right answer and you would beat yourself up either way. The ideal, as Minh says, is to bring the resus bay to the patient if the resources are there. Definitely grey zone!
Very interesting indeed. First when you mention ” if someone would have said do it they would have” it remind me of : http://en.wikipedia.org/wiki/Milgram_experiment So i think the issue not so much an ethical one but our aversion to loss or been wrong. In her book: http://www.ted.com/talks/kathryn_schulz_on_being_wrong Discuss that subject. Our aversion to loss or been wrong sometime will make us be irrational. In nursing I notice a similar trend. We used to report safety issue via report that was more interesting in blaming someone then finding a solution. When they change that approach for finding a solution or prevention,… Read more »
Thanks for speaking up MountianRN. I think you make some good points. I admit I have no knowledge of how physicians are trained. I received my training in a rural setting and I have worked here since I got out of school. There is no medical school in my state! However, I think we are seeing similar problems in new nurses. Being tentative, inexperienced and lacking knowledge are all expected when we are new at anything. I agree with the new push that critical thinking should be the focus of schooling, as it is the most important skill to our… Read more »
And I spelled Mountain wrong. Not a banner week for me in the spelling department.
Actual critical thinking is a skill that help in all area of life. Sadly it is not widely taught . Back in ancient Greece every citizen require to represent his own in front of others. They learn rhetoric, argumentation to do so. I believe, in nursing, learning those skills, dealing with difficult people, critical thinking and having not just teacher but mentor to built confidence would help alleviate. Becoming MacGyver of those situation. Like Minh mention on earlier post, we can train for every situation, but Mac with his swiss knife always manage to find a solution. Let’s be better… Read more »
yes, as a society we have let these critical thinking skills slip. in fact any Socratic challenge is usually viewed as offensive, rather than an opportunity to defend thinking.
I have had in my 36 year career many occasions where I had to give myself permission to do something in the absence of a doc. In these cases I could have lost my license, been reprimanded for out of scope of practice. But, I did it anyways and would do it again. I have been in many situations with junior residents and a patient spiralling down, and have taken over as a nurse and start active treatment, until a more senior resident arrived or a staff man arrived. I would alway take responsibility for my actions, and I would… Read more »
absolutely Stan
As another Swedish doctor I have a different view from my friend Mikael. In anaesthetics/icu I will always be questioned if I don’t do things. I think it’s a bit different for the orthopods here (hi mikey welcome to us soon). My mentor says constantly that we should focus on doing the right things with our patients not on trying to avoid doing the wrong things. Also there’s not a snowflakes chance in hell of him coming in to stand by my side while I intubate, so a fair bit left before we are in the same position as the… Read more »
love that perspective. Tom
Great Wee that really hit home. As a resident, I love Shock Trauma for a plethora of reasons, but one definitely is like you said, they are not afraid to act and to do. They try everything for patient. That’s the type of physician I would want for my family or myself, so I feel its the kind of physician I want to become. We are all going to make errors, but I feel at least with an error of commission, you tried and were unsuccessful instead of omission, where you just didn’t even give the effort. I get really… Read more »
damn near impossible to know without showing up. everyone can talk a good game.
Meanwhile, I can intubate all day long with no supervision or asking permission from anybody…
(I think this has been stated in other ways above)
Docs, you think you have pressure to not act? I wish you had none, but remember us Paramedics as we can be professionally destroyed for doing what we know needs done but falls outside our protocols. It is beyond frustrating to see the solution your patient needs and know that I cannot perform it.
very useful concept – it is the opposite in polarity with respect to application in criminal law: errors of commission are more serious than errors of omission because the criminal law abhors wrongful convictions based on false facts.
I work in the pre-hospital setting and am a current paramedic student, I say that so you know I am still learning and always will. In some places across the country we have services that just don’t run that many calls in a shift. So the experience level is lower overall. So how do we combat this? Well we have to train more on skills we don’t perform often. Great! And there are a lot of services that do just that, BUT there are several that don’t and it is left up to the individual to be “on top of… Read more »