Semin intervent Radiol 2015; 32(01): 001-002
DOI: 10.1055/s-0034-1396955
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Making Mistakes in Interventional Radiology

Charles E. Ray Jr.
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Publication Date:
02 March 2015 (online)

This issue of Seminars, although entitled “Morbidity and Mortality” (M&M), is really an issue devoted to our mistakes. I thank our authors for their openness in discussing some of their worst complications so that we all may learn from them. I would also like to thank Brian Funaki, MD, for his cameo appearance as a guest editor.

I believe the concept of “M&M” is largely one that is medicine-centric. All medical specialties have their own peer-reviewed conferences, and I am certain that all of us remember M&M conferences from multiple different departments in medical school. I actually cannot think of another field outside of medicine in which errors are so openly discussed. This concept is particularly interesting to me since medicine is also one of the most litigious professions, and it would seem that the combination of openness and litigation would not be a match made in heaven. I think this should be taken as a huge compliment to all of us in medicine, in fact, that we are willing to take the risk of exposing ourselves legally as a way to make sure the lessons are learned and the same mistakes do not happen again.

I have coordinated several sessions on complications at different meetings (I guess I have come to be the go-to person for complications; not exactly the reputation I was looking for, but there you have it). Some of what I have learned from being involved with these sessions interest me. First, when setting up the faculty for these sessions it is better to choose faculty members with some experience. I do not know if older and more seasoned faculty members simply understand that complications are just part of the practice of medicine, or if they care less what colleagues in the audience may think of them, or if they just frankly cannot remember all of their complications, but whatever the case older practitioners give the best M&M lectures. Second, we all take these complications seriously. I have seen internationally recognized experts in our field break down in tears when discussing some of their complications. The time to be concerned, I suppose, is when they do not cry.

Sadly, as a practitioner some of my most memorable lessons have come from patients who suffered complications due to an error on my part. I do not know why that is the case—why do we learn better from mistakes resulting in harm rather than “near misses”—but in talking with partners of mine I think my take on this is nearly universal. And although serious complications, including deaths, that result from our own hands make us better physicians in the end, that is a small consolation for the family of the patient or for your family of health care providers. The only thing that would make such a horrific situation worse still would be not to learn the lesson from the case, or not to share those lessons with as many colleagues as possible.

I have routinely told my fellows—frequently after their first really bad complication—that I have three rules of complications. First, if you have a complication and do not recognize it, you should not be doing the case because there is a knowledge gap that you need to address. Second, if you have a complication that you recognize but choose to hide it, you should not be doing the case because you are unethical. Third, if you have a complication, and recognize and treat it, but turn around and do the same stupid thing the next time, you should not be doing the case because you are kind of an idiot. If, however, in retrospect you have a complication and do not break any of the three rules, then it is just a complication and it is time to move on. In some ways those are the most difficult to recover from, those complications where you do not feel that you did anything incorrectly. It is the ones we cannot learn from that are the scariest.

I am proud of our field to be willing to step up to the plate and assume responsibility for their complications. Without the openness of doing so, our specialty—and most importantly our patients—would be placing themselves at far greater risk than they already are. Thanks again to the authors of this issue of Seminars for their willingness to be involved in such an important project.