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October 2017

Mistakes Were Made (by Me)

Author Affiliations
  • 1Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
  • 2Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Intern Med. 2017;177(10):1422-1423. doi:10.1001/jamainternmed.2017.3781

I still remember taking care of a particular patient when I was a medical student. She was a middle-aged woman with cyclic vomiting syndrome who presented with nausea, vomiting, and abdominal pain. The plan was the same as always: nothing by mouth, intravenous fluid, antiemetics, and discharge once she could eat. On hospital day 2 she suddenly developed chest pain. An electrocardiogram (EKG) revealed ST-segment elevations, which prompted emergent cardiac catheterization. I reviewed her admission EKG and realized it had identical ST-segment elevations. I became nauseated myself, because no one from our team had looked at the initial EKG. The angiogram excluded acute coronary syndrome, but the guilt of a potentially tragic mistake remained. I wanted to share this experience with my colleagues so we could learn from it. I asked a colleague for the best forum to discuss our mistake, and my colleague gestured “hush” and said, “There is no need to tell anyone because she didn’t have plaque rupture.” I was confused by that reaction. Was I to be ashamed of my mistake?

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