Reflection on medical errors: A thematic analysis.

BACKGROUND

As there is a need to prepare doctors to minimize errors, we wanted to determine how doctors go about reflecting upon their medical errors.

METHODS

We conducted a thematic analysis of the published reflection reports of 12 Dutch doctors about the errors they had made. Three questions guided our analysis: What triggers doctors to become aware of their errors? What topics do they reflect upon to explain what happened? What lessons do doctors learn after reflecting on their error?

RESULTS

We found that the triggers which made doctors aware of their errors were mostly death and/or a complication. This suggests that the trigger to recognize that something might be wrong came too late. The 12 doctors cited 20 topics' themes that explained the error and 16 lessons-learnt themes. The majority of the topics and lessons learnt were related more to the doctors' inner worlds (personal features) than to the outer world (environment).

CONCLUSION

To minimize errors, doctors should be trained to become earlier and in time aware of distracting and misleading features that might interfere with their clinical reasoning. This training should focus on reflection action and on discovering more about doctors' personal inner world to identify vulnerabilities.