The Mistake

As I read the posts and comments on this incredible site, so many things come to mind. Lately, a young nurse with whom I once worked has been in my thoughts. Lisa (not her real name) was a lovely person -- a wonderful mix of lively, professional, caring, committed, open, eager, and responsive. She was a relatively new nurse, and she looked up to the more experienced nurses with respect and a willingness to learn. Her patients loved her, and the team loved her. It was a pleasure working with her.

To this day, I'm not sure how it happened. Lisa was working with a young patient, a woman whose bone marrow wasn't recovering well from her most recent chemotherapy and who needed multiple transfusions over the course of her hospital stay.

The young woman was a tough patient, and hers was a very involved, very challenging family in many ways. They were demanding, anxious, and always looking over everyone's shoulder as we worked. And they made Lisa nervous. I know, because she and I talked about it. In particular, we talked about how to handle the many questions they asked about Lisa: how old she was, how long she had been on the floor, how long she had been at the hospital, etc.

Lisa felt they were questioning her ability to do her job, and perhaps the pressure created a kind of self-fulfilling prophecy. However it happened, there came a day when Lisa made a mistake -- a potentially terrible mistake. She set up a transfusion for the patient and accidentally hung the wrong bag of blood.

On that day, the family's hypervigilance paid off. The mother of the patient noticed almost immediately that the code on the bag did not match her daughter's code. She found the nurse, and the transfusion, which had barely begun, was immediately stopped. The patient was fine. The nurse, in an act of utterly genuine and heartfelt humanity, made what some in the hospital deemed another terrible mistake. She apologized.

The patient's mother spoke with me over and over again about this episode. She was terrified that something like it might happen again, but she did not blame Lisa. She was truly grateful that Lisa cared enough not to try to cover it up. She talked about the importance of that apology, how it made her daughter and her whole family feel like real people, how it made them feel good to know that they counted, that they weren't "just numbers," and how certain they were that this particular mistake would never happen again, "because the nurses care so much."

That apology -- that acknowledgement of human error and human concern and care -- was a brilliant mistake. Because of that apology, the family remained relatively calm. They were angry and upset, but the apology disarmed them. It made it instantly clear to them that the error was not a result of an uncaring attitude. It made them acutely aware of the fact that the nurse who did it was a real human being doing the best job she could. The depth of her concern for her patient was suddenly and powerfully brought to light through this one simple act of apology.

A quick search on PubMed will call up numerous articles discussing the impact of apologies in medical practice and the relatively recent creation (most in the 1990s) of apology laws in many of our states. The Hastings Center Website has two interesting articles: "The Limits of Apology Laws" by Rebecca Dresser and "Las Ofrendas: Mourning After Medical Harm" by Nancy Berlinger, which covers the importance of both acknowledging the errors that happen and giving our patients and families time and space to speak about them.

Ultimately, the most profound healing happens when we cut through the embarrassment, fear, and concern about legal issues or reputations and reach out on a human level.

As far as I am concerned, apologies are never a mistake.