Lessons Hard Learned: a Reflection on Error

Dr Peter Fritz is an ED Physician and amazing landscape photographer. (Check out his site) Many of you might know him as the co-author of the original Vortex paper.  Peter has allowed me to use this image of a solo mangrove at high tide in Broome titled “Alone in the Fog”.  I think it perfectly illustrates my feelings about one of the low points of my career.  Feeling alone, one’s mind full of the fog of doubt, it can be hard to reflect clearly.

Image: Peter Fritz
“Alone in the Fog”


I recently made an error.  I harmed a patient.

Errors occur, they are inevitable in ED practice.  All we can do after such an event is to minimise the further harms to the patient and to reflect.  Reflection is important to allow one to learn.  More crucially it allows us to move past the shame and blame and try to make amends.  Without reflection, we can get stuck in self-loathing and guilt.  So this is my attempt to reflect honestly and learn those hard lessons.

My error was simple really.  I placed a central line into a patient’s carotid artery.

I have made this mistake once before, nearly twenty years ago when I was a trainee doing quick and blind central lines, sans ultrasound on a busy vascular surgery list.  Since then I have learned a lot and placed plenty of lines safely.  As a rural generalist in a small hospital with our modern approaches to sepsis, I only place a handful of central lines each year.  I probably have to supervise more than I actually do and as such my practice is sparse. 

Classic error.  It is what we all fear when placing jugular lines.  And yes, it was me… the guy who spends a lot of time thinking about and teaching ultrasound, espousing patient safety and practising procedures.  This is something in which I take a lot of pride. Which is why this error left me feeling profoundly inept.

I know the immediate cause of the error.  I lost my needle tip as I advanced the wire into the vessel. This is a fundamental sin when guiding a needle – don’t move the needle unless you know where the tip lies.  I must have taught this a thousand times… and yet I committed the sin. I then failed to recognise the mistake before proceeding to dilate and thread the catheter.   

Last year I wrote a post on some simple techniques to avoid this exact error. [The Best Central Line Ever: … Tribute]  I am sure that I did neglect much of the content in that post.  I skipped many of the safety steps.     However, it would be wrong to say that this error was due to a lack of knowledge or inadequate skill.  This was a cognitive error.  Failure to translate knowledge and experience into the safe execution of a task.

So the question becomes why.  Why did this occur on this particular shift?  What was happening in my brain that lead me to take short cuts, lose concentration and not recognise the error before it was too late?  Put simply: why the brain fade?

I will start with a wide view of my internal mental state and then focus onto the actual error.  I make no excuses, we all have busy minds and lives.  However, I believe it is important to view any error in the context in which it was made.  These things do not occur in a vacuum.  Understanding the background can help understand the solutions going forward.

Life at home is hectic.  It is the school holidays and we are in the process of packing up our house to move in a few weeks.  Sleep has been broken by excited children, monsoonal storms and on-call duties.  Lately, work has been a refuge from the cheerful chaos of childcare.  However, I have been arriving at each shift thinking about all of the tasks we need to get through to move home after a dozen years of domestic stability.

I was working night shifts.  Nights in Broome can go a few ways.  Sometimes it is just a slow trickle of drunken injuries and febrile babies… sometimes it is crazy.  This night was the latter.  We work solo after 11 p.m.  The four evening staff go home to leave a single doctor covering the ED, ward and taking calls from the region.  Task saturation is never too far off.

Handover time is usually a pleasant chat, catch up with the events and discussion of plans. This night was busy.  I hit the floor running.  All our bays were full and there were a series of unknowns in the waiting area.

In the wet season, we rely on a series of locum doctors whom we often know little about.  This was the case on this shift.  I was taking over a busy ED from a team who were either junior or foreign to me.  As I took handover my inner monologue was taking notes on all the possible problems and issues I would have to go and check out firsthand… just to be sure.   Fortunately, I work with a fantastic team of nurses who make anything possible.

My big concern was the septic dialysis patient who had multiple sources for her illness.  Handover mainly involved getting the right antibiotics charted.  There was the casual mention that the only IV access was a 22 gauge in the non-fistula arm… mental note: fix that!  For the moment though there were more urgent matters.  A bleeding wound, a possible appendix and a suspicious sounding headache at triage.

It was at about this time that the 22 gauge cannula fell out.  I was busy doing other things so one of the nurses promptly placed another small drip in the same arm.. problem solved… or at least avoided for now.  I carried on doing other things.  Little did I know that that was the last good vein on offer.

About half an hour after my evening colleagues left the patient’s BP started dropping.  That little drip was starting to look very inadequate.  I made two quick decisions.  First, we needed a central line and second, the patient needed transfer to ICU.  The trajectory was not looking suitable for our northern HDU.

Organising transfers is an onerous, administrative task.  Sometimes half a dozen phone calls telling the same story three times.  All that time on the phone meant more patients arriving and more unknowns.  We do have an on-call system whereby we can call back a senior doctor.  However, it is usually reserved for traumas and major issues requiring a trip to the theatre.  The unwritten code is that we do not call in help for “general busy-ness”.  As I spoke to the delightful ICU registrar (more on him later) I was gesticulating to the nurses to take our sick, septic patient to the Resus area and prepare for a central line.

After I hung up I walked to Resus thinking… “that does not look like an easy neck”.  However, we had just started a peripheral metaraminol drip to get the BP up and I knew that we needed reliable access for the 12-hour transfer ahead.  So I did a scout scan to look at the options and the right IJ was the only access point that seemed safe.  There was a very proximal fistula in the left arm and long scars from previous attempts at fistulae. The patient had a short, thick neck and the views were not text-book, but I could see the target.  Crack on!  Prep, drape, anaesthetise the area.

I remember thinking that the angle I was getting was awkward. The IV pole was in the wrong place, but I just decided to work around it, lean in a bit.  The US images showed a deep IJ and the neck anatomy made it hard to get a view where the carotid was not partially behind the vein.  I should have stopped, rethought, maybe reconsidered another site.  Tick, tock… all the other unknowns were building out there.

Here is where pride comes before the fall.  I know this procedure.  I practice it.  I think I am pretty slick for a part-timer.  So instead of calling my mate back to help out in ED, I decided to get it done quickly and get back on the floor.  Bad call.  I should have recognised that my mind was not focused and that back up would afford me time to do it right.  Slow is smooth and smooth is fast.  But no; I chose fast over safe in this case.

So on I went.  The view was OK, I advanced the needle. I got a bloody flash and threaded the wire.  The patient was particularly short-necked and so after just a few centimetres the wire tickled the heart and we had VT on the monitor… quick pull back … and lost my view in the moment of distraction.  The wire must have come back into the barrel of the needle.  When I advanced it again it went down easy… somewhere.

Here is the thing.  Read my post on “the Best Central Line Ever” – I teach that one should rescan the neck at this point to check the wire is in the vein.  But I did not do so.  Confident that the line had “gone in easy”.  I decided to skip that step and move onto dilation.  I could hear a few loud yells from the front bays, I wanted to get this done ASAP.  The catheter threaded easily.

I knew that the retrieval team would want to check the line so I drew a gas and handed it off to the nurse…. the PaO2 was 200!  In disbelief, I transduced the line and the blood pressure was identical to the radial arterial line that I had confidently placed just an hour before.  My heart sank.  I felt a wave of sweat and nausea beneath my mask.  I had harmed my patient.  I had made a bad situation worse.  Worst of all I still did not have a decent line to keep her going.  Now I had even more tasks to complete to get her to safety.

The next emotion I felt was anger or at least frustrated annoyance.  Not towards myself but toward my patient.  I imagine that we all feel this at times when things go poorly.  Maybe it is the culture in which we grow up?  But I remember thinking that this was their fault, just for a few moments.  That she were somehow to blame.  The neck was too fat, the patient didn’t maintain a good position in their delirium, if she hadn’t skipped dialysis we wouldn’t be here… 

These are dark thoughts that would only lead to dark places.  After a few deep breaths, I recognised them as such and moved back to reality.  This was my error.  I hold all the responsibility and need to fulfil the trust that our patients’ place upon us every day.

It was at this point that I realised that I was not a superhero.  I asked the second-on to be called in.  I needed to concentrate and get his right.  I needed help.  I called the receiving ICU to let them know what had happened and get some advice.  Here is where fate dealt me a fine card.

The ICU fellow was none other than Dr Stuart McLay [ @SVBMedic ].  I have been following Stuart on the FOAMed world for years. He gave some great talks on supporting one another at the Perth ACEM ASM last year.  Then, in the small world of FOAM, we found ourselves at the same baggage carousel en route to SMACC in Sydney last year whereupon we shared an Uber and a conversation to our hotel.  As is often the case in the FOAM community, the great folk online are even better in person.   Stuart is a kind soul and has been a strong voice in our community when it comes to doctors wellbeing, mental health and safe workplaces.

Stuart listened and gave simple, pragmatic and sensible advice.   He offered to make the calls to the various people who needed to know about my error and could help fix it.  This was a great burden lifted.  It was not a story I wanted to tell three times!  Most importantly he never questioned the why or how.  I did not feel like my competence was under judgement.

Stuart assured me it was going to be OK.  An hour later he checked in by text to make sure both I and my patient were OK.  He took ownership of my problem.  This was the most wonderful exchanges I have had over many years of speaking to specialists in faraway places.  This is precisely the way I want to help out colleagues in the future.  Thank you, Stuart, you talk the talk and walk the walk.

Some days after the event I had the chance to chat with Stuart again and he described his simple approach to helping colleagues who have made errors (or even just perceived that they have done so).  I want to share his wisdom here:

  1. There is nothing that one can say, or do that will change what has passed.  Going over the error or “Monday morning quarterbacking” is not helpful in the moment.
  2. The actual error is a powerful learning moment for the doctor.  More so than any teaching one might offer.
  3. The doctor will be feeling awful.  Be empathetic to this and acknowledge it.
  4. Recognise that there but for luck/fate/divinity this could have been me on the other end of the conversation.  Imagine how you would want to be counselled at the moment.
  5. There are many things that one might do or say in the situation.  Some will make things better, some will not.  Ponder the options and choose the “better”.

For me – the most important part of the process was being able to follow my patient.  After all, it is they that have suffered the real injury here, not I.  Checking in and being informed of the progress and complications was very helpful for my coping.  I think we doctors tend to imagine the worst outcomes when we make errors.   So having actual information to digest and reflect upon further made it a lot easier.    Thanks to my colleagues and Dr Stu McLay I was never left in the dark to imagine the worst. Ultimately the patient did well.  There was a series of steps and procedures which she needed to go through as a result of my error, but in the end, there was no permanent harm.  I look forward to having the chance to meet and apologise to her face-to-face, once the medicine and geography allow.

After reflection and time I feel more like a part of a mangrove forest growing in the murky waters that ebb and flow with the tides. Not alone, part of a community.



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