“Did we forget Lovenox?”
Its 1:30am on my last call night of my Medicine Sub-I. My resident and I have finished seeing our new admits and we’re going through their orders to make sure they’re tucked in for the night.
I check them by linking each problem to a corresponding intervention. Diabetes? >> Insulin. COPD? >> Breathing treatments. Alcohol use disorder? >> CIWA. One problem is universal in all inpatients: blood clots. Due to their diseases and immobility, inpatients are at high risk of DVT and pulmonary emboli. That is why nearly all of them get enoxaparin (Lovenox), which cuts the risk by almost a third .
But as I parse through the new admit’s chart, I see it isn’t ordered. My actions are a reflex: Order Tab >> Search >> ‘e…n…o…x…’. My resident is looking over my shoulder; “Why do you want to anticoagulate this patient?” I begin to answer. Then stop. A knot in my throat: The patient has a GI bleed. I feel a chill; I was about to turn their stable trickle into frank hemorrhage.
I made a big mistake. No harm came from it, but I know it’ll gnaw at me for a time. Truth is, I feel a paradoxical satisfaction when I see such errors in myself. I love the insights that I can glean from them. In this case, three insights stand out:
First, I don’t do my best thinking after midnight. Would I have recognized the folly of anticoagulation at a refreshing 1:30pm? I am not sure. But the risk of such a mistake would likely be lower as I am less fatigued and less distracted by thoughts of sleep.
Second, I am reminded of Daniel’s Kahneman’s marvelous book Thinking Fast and Slow. Therein, he proves that humans are lazy; that I am lazy. He shows that for the majority of our decisions, you and I will rely solely on intuition; we’ll expend effort on reasoning only if absolutely necessary. My midnight mistake was not due to a lack of knowledge. It was pure laziness. I knew most hospital patients benefit from anticoagulation. My failure was to ignore the question: “how is this patient different?”
Finally, the lesson encapsulates the benefit of teamwork and of oversight. Whereas I accrue medical knowledge with the intention of becoming independent, this error reminds me that my training is far from complete. It shows the benefit of forcing me to make decisions, to defend them, and—through my mistakes— to refine my thought process and avoid them when I become an intern.
I do not relish my mistakes; I am not proud of them. However,they are unique opportunities for me to discover myself. After all, a lesson learned on the wards is more poignant than one heard in a lecture and more memorable than one read in a textbook. By confronting my errors and reflecting on their causes, I’ll recognize future situations where they may recur and prevent myself from repeating my mistakes.
- Samama, M.M., et al., A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med, 1999. 341(11): p. 793-800.