By Jocelyn George, Pharm.D., pharmacist, BioMed Specialty Pharmacy, Livonia
My earliest memory of professionalism was the white coat ceremony in which I, with other classmates, donned the white coat and recited the Hippocratic Oath. This was the foundation of my practice in patient care. Throughout the years, the advent of modern medicine has brought positive changes to healthcare and shed light on disconnects within medicine that has led to medical errors. The Institute of Medicine (IOM) published its report in 1999, To Err is Human, and stated that medical errors were the fifth leading cause of death.1 Moreover, Makary et al evaluated the studies from 2000-2008 cited in the IOM report and concluded that medical errors were the third leading cause of death the U.S.2 Both reports have concluded breakdowns such as inefficient processes that lead to system problems and lack of standard protocols. Risk analysis tools such as the ‘Swiss Cheese Model’ and ‘Root Cause Analysis’ identifies those involved in the process and the ‘holes’ in the system that lead to errors. The focus is primarily on restoring the patient, the primary victim; however, studies conclude there is a second victim, the healthcare professional. In 2000, Dr. Albert Wu identified the healthcare professional involved in an incident as the second victim and provided the following definition, “Second Victims are healthcare professionals who are involved in an unanticipated adverse patient event, in a medical error and/or a patient related injury who become victimized in the sense that the provider is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base.”3 This article aims to bring awareness to the post-traumatic effects of medical errors on second victims and the support programs available in hopes to further a culture of safety for better patient outcomes.
Waterman et al. writes, “Medical errors are unfortunately inevitable in complex healthcare environments.”4
Although this may be obvious, it remains a harsh reality. Research using surveys of second victims expound on the emotional impact of medical errors such as isolation, profound shame/guilt, fear of losing one’s job, decreased job satisfaction, doubt regarding clinical abilities, fear of reputation to litigation.3,4
A survey of 3,171 physicians from the United States and Canada have reported effects of errors such as increased anxiety (61 percent), decreased confidence as a physician, (42 percent), inability to sleep (42 percent), job dissatisfaction (42 percent), and concern for professional reputation (13 percent).4
In addition, as the severity of error increased, the likelihood of emotional impact increases. Astoundingly, 90 percent of the physicians reported that the institutions did not provide support. Furthermore, healthcare professionals that do not receive care for current distress can lead to an increased chance for future errors. West et al. surveyed internal medicine residents every three months regarding quality of life in those that have reported errors.5
The survey demonstrated that the emotional distress experienced by residents has led to further burnout, depression and reduced empathy, which lead to a vicious cycle of errors. Although factors such as professional stigma, lack of medical culture that encourages sharing and protecting reputation may impede change, there are programs available to provide assistance to those in need.
Medically Induced Trauma Support Services (MITSS) is an organization founded in 2002 by Linda Kenney that provides support to patients, families and clinicians.6
As a patient who has encountered a medical error during a procedure, Kenney was personally affected by a medical error, but she also saw the impact on the physician involved in the procedure. MITSS offers an online toolkit with resources for organizations looking to start a clinician support program. There are institutions that have developed programs such as Resilience in Stressful Events (RISE) at Johns Hopkins Hospital and “forYOU” program at University of Missouri Health Care. In 2010, Edrees and associates of various sectors of patient safety at the Johns Hopkins Hospital developed the peer support program, RISE.7
Peer responders were healthcare professionals who were trained to navigate calls from affected staff and provided emotional support. Data collected from surveys over a five-year period indicated 66 percent of staff involved in an unanticipated adverse event would have responded positively to support from a colleague. Similarly, S. Scott and colleagues at University of Missouri Health Care forYou team have developed a peer support program with real time availability when an incident occurs.8
Data has yet to be published concerning the effectiveness of the peer support group to reducing turnover and consequently reducing medical errors. As efforts for improving patient safety evolves, there is evidence to further the idea of developing a culture of sharing in hopes to strengthen systems of healthcare.
Since the 1999 IOM report, advancements in healthcare technology such as Computer Physician Order Entry and Barcoding have reduced the error rates. These represent the parts that contribute to the story of what the National Patient Safety Foundation considers as ‘total systems safety.’9
This is a culture of safety that starts with the core values of how we design processes to give care to patients. As with any culture, there are deficiencies, but the goal is to as a community to fix, learn and improve to build a stronger community.
Kohn LT, Corrigan JM, Donaldson MS (2000). To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press. https://www.ncbi.nlm.nih.gov/books/NBK225182/pdf/Bookshelf_NBK225182.pdf. Accessed December 2016.
Makary MA, Daniel M. Medical error- the third leading cause of death in the US. BMJ
Scott SD, Hirschinger LE, Cox KR et al. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Quality Safety Health Care
Waterman AD, Garbutt J, Hazel E et al. The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada. Joint Commission Journal on Quality and Patient Safety
West CP, Huschka MM, Novotny PJ et al. Association of Perceived Medical Errors With Resident Distress and Empathy: A Prospective Logitudinal Study. JAMA
Kenney, LK. Medically Induced Trauma Support Services. http://www.mitss.org/healthcareorgs_home.html. Accessed December 2016
Edrees H, Connors C, Paine L et al. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: A case study. BMJ
Scott, SD. Second Victims: Gaining a Deeper Understanding to Mitigate Suffering. Per-operative Services Grand Rounds. Beth Israel Deaconess Medical Center, Boston MA. Sept. 1, 2010. Presentation
Gandhi TK, Berwick DM, Shojania KG et al. Patient Safety at the Crossroads. JAMA