Reflect on a mistake made in the hospital, its impact and lessons learnt

Mistakes in medicine can be a difficult topic to openly discuss. While mistakes aren’t often pleasant to dwell on and evaluate, it is one of the best learning opportunities that exist in our field, and it’s only by talking about them that we can educate ourselves and others on how best to avoid that same mistake again in the future.

A little over a year ago, I was a baby-faced final year medical student who had just sat their exams and looking forward to their elective. Obviously, the early part of 2020 didn’t go to plan. After a bit of back and forth, it was decided that we would be allowed to enter the medical workforce 3 months early as interim F1 doctors. I was allocated to a district hospital I had never had a placement at, was not due to work at over the next 2 years and was a 90 minute drive from home. Nevertheless, I was thrilled – and better still, I was going to be working in Trauma and Orthopaedics.

Fast-forward a few weeks, a patient was admitted as a potential cauda equina case, which had quickly become my bread and butter. History and examination, MRI and refer to the nearest specialist centre. But today the radiology viewing system was down so there was no MRI report. I explained this to the specialists and had the images transferred. Not long later, we were given the green light to discharge the patient; their MRI was normal. I let the consultant know and wrote the discharge letter.

A week later, there was a message for me on the ward. It was the patient wanting to know their formal MRI report. I looked at the report (the system was now back online) with the anticipation I’d call him and say the words “no acute pathology”.

But, no.

“In keeping with cauda equina.”

I couldn’t believe it. I looked at the scan. There it was. Even I could see it. I ambushed their consultant in fracture clinic and explained everything. They called the specialist unit - they had never received the scan. They had an old scan. A normal scan. We called the patient to see how they were doing. They were well, cycling, going to work, “I’m much better, Doc”.

Phew. The consultant took it from there.

It was something that should never have happened. And, while it wasn’t directly my fault, I felt awful. Why hadn’t I looked at the scan before I referred? But I knew the answer to that – I was an interim F1, I was still building confidence in chest X-rays, let alone whole spine MRIs! Like never before, the Swiss cheese model made complete and utter sense. Now, regardless of what scan, regardless if it has a report, I always look at the images. I’ve picked up so many pathologies by doing this, I now it has benefited my patients and colleagues. And always ask for help! You are never alone in medicine!

About the Author

Lotte Weenink - SUTURE UK September Blog Competition Winner

Lotte Weenink is a an academic FY2 in Nottingham with an interest in trauma and orthopaedic surgery.