Launchpad: Making the Most of Medical Mistakes

Early in my career, I made a mistake that I’ll never forget. Later in my career, a colleague almost made that very same mistake, but I was able to help them avoid unnecessary hurt because of what I had learned.

The first case was a 2-year-old crossbreed dog presented for vomiting and lethargy. Plain radiographs were inconclusive, and back then, we still relied heavily on barium studies. This dog couldn't even keep the barium down. Given his age and the unrelenting vomiting, I was convinced he had an obstructive foreign body, so I performed surgery. 

I didn’t find an obstruction, and I had no answer for his owner. The overnight facility ran a parvovirus test after learning the dog had never been vaccinated. The result was positive.

The dog survived, thankfully, but only after several days of intensive care. I still remember the guilt that came crashing down. I omitted a crucial history question. I put this patient through an unnecessary surgery. I made the wrong call.

For weeks, I replayed everything in my mind: the presenting signs, the diagnostics, my decision-making. I talked it through with mentors and made a plan to prioritize vaccine history in every acute vomiting case from then on. 

Years later, I was in the treatment area when a colleague brought back a young dog for an exploratory laparotomy. Fluids and preoperative medication had already been started. I asked about vaccine history. My colleague thought they were current but went to double-check. Turns out, the dog had only received one DA2PP (distemper, adenovirus type 2 [hepatitis], parvovirus, parainfluenza) vaccine at 8 weeks of age. This time, we caught it before the incision and spared everyone the pain I’d once felt.

The hard truth is that you will make mistakes. We all do. But medicine isn’t about never being wrong. It's about continuing to show up for your patients and learning from every misstep along the way.