When a medical error occurs, the patient is not the only person affected. Pediatric intensivist Brian Flaherty and psychologist Megan Call describe how caregivers can be impacted by medical error and provide strategies to cope.
By Brian Flaherty and Megan Call | 5 minutes
LEARNING OBJECTIVES
After reading this article, you will be able to:
- Define secondary or occupational trauma.
- Describe the effects of medical errors on care providers.
- Identify strategies used to help cope when medical error occurs.
CASE STUDY
It was a busy night in the ER and the patient with strep throat was the least of the doctor鈥檚 worries鈥搖ntil the patient developed anaphylaxis. In her haste to treat the patient, the doctor gave a penicillin injection without noting a prior severe reaction to amoxicillin had been documented. Within moments of the injection, the patient began having trouble breathing. The mistake was quickly realized and treatment begun, but the patient still required intubation and several days in the ICU. The patient survived, but the doctor was left wondering how she could have made such an error. She worried it was only a matter of time until it happened again. What is happening?
MEDICAL ERROR AND SECONDARY TRAUMA
We strive for perfection in the care we provide, but, despite our best efforts, errors do happen鈥損atients do get hurt. While initial concerns correctly turn to caring for the patient, we need to also address the feelings of guilt, shame, and anxiety that care providers feel when things go wrong. Family practice physician David Hilfiker first described the devastating effects of medical error on caregivers in his powerful 1984 New England Journal of Medicine article, (1) This experience has come to be defined as secondary or occupational trauma, describing a health care provider who feels significantly impacted or traumatized by the adverse event. (2鈥4) The care provider is left to cope with feelings of guilt, shame, and anxiety while also questioning their competency to provide care in the future.
IMPACT OF SECONDARY TRAUMA ON HEALTH CARE PROVIDERS
It鈥檚 estimated that 10鈥40% of care providers will experience secondary trauma. As a result of the stress, health care providers have reported symptoms related to depression, burnout, and post-traumatic stress disorder. In addition to the harm incurred by the provider, these feelings may also negatively alter the provider-patient relationship. There鈥檚 also an indication that these feelings may affect future event reporting, curbing system-wide improvement. (3, 5)
EFFECTS OF SECONDARY TRAUMA
Health care providers who experience secondary trauma report feeling:
- Hopeless/helpless
- Disconnected from others
- Extreme fatigue
- Difficulty falling/staying asleep
- Exaggerated startle response
- Easily irritates/feel on edge
- Decreased job satisfaction
- Increased substance use
- Fear of future errors and decreased confidence in skills
COPING WITH THE STRESS OF A MEDICAL ERROR
Following a medical error, a health care provider may go through a series of stages of recovery that will ultimately see them find ways to cope and continue on in their practice, or leave their career.
STAGE
HOW IT WORKS
QUESTIONS ASKED
- Chaos & Accident Response
Medical error is realized and efforts are focused on getting help to the patient.
- How did that happen?
- Why did that happen?
- Intrusive Reflections
Events are re-enacted and providers begin asking 鈥渨hat if鈥 questions while coping with early feelings of inadequacy.
- What did I miss?
- Could this have been prevented?
- Restoring Personal Integrity
Seek confidence from trusted peers and begin to worry whether the trust of other peers can be regained.
- What will others think?
- Will I ever be trusted again?
- How much trouble am I in?
- How come I can鈥檛 concentrate?
- Enduring the Inquisition
External repercussions that could lead to litigation or affect future career prospects and licensure.
- How do I document?
- What happens next?
- Who can I talk to?
- Will I lose my job/license?
- How much trouble am I in?
- Emotional First Aid
Providers seek emotional support through personal, professional, or institutional avenues.
- Why did I respond in this manner?
- What is wrong with me?
- Do I need help?
- Where can I turn for help?
- Moving On
Providers may 鈥渄rop out鈥 due to stress and self-doubt, 鈥渟urvive鈥 with lingering stress, or 鈥渢hrive,鈥 reporting growth and learning from their experience.
- Is this the profession I should be in?
- Can I handle this kind of work?
- How could I have prevented this from happening?
- Why do I still feel so badly/guilty?
- What can I do to improve our patient safety?
- What can I learn from this?
- What can I do to make it better?
Figure 1. Six stages of secondary trauma. Adapted from .
STRATEGIES TO ADDRESS SECONDARY TRAUMA
TAKE CARE OF YOURSELF
Strategies that have been demonstrated to increase resilience and prevent burnout can also be utilized to prevent second victim syndrome, such as using simple mindfulness strategies, exercising regularly, engaging in meaningful activities outside of work, having supportive relationships, and addressing routine health needs.
KNOW WHAT TO EXPECT
Health care providers can also benefit from learning what to expect cognitively, emotionally, and physically following an error. It is normal to experience difficulty concentrating, repetitive thoughts related to the error, sleep issues, headaches, stomach or back pain, and feelings of sadness and guilt for a few days following the error. Expect these symptoms鈥揹o not treat them as signs of weakness or being an unskilled provider.
HOW TO SUPPORT OTHERS
As a team leader, you can address secondary trauma by establishing and maintaining a culture of support and by becoming familiar with local resources, such as U of U Health鈥檚 Resiliency Center. The Resiliency Center provides confidential screening and access to a number of services that foster wellness and resilience for all employees at U of U Health.
As a peer. Clinicians are overwhelmingly more likely to seek support from peers instead of mental health professionals or Employee Assistance Programs (EAPs). By listening and providing supportive comments, colleagues can talk through the error, understand why it occurred, and better cope with the emotional stress. Because peer support is so important to recovery, formal peer support networks to address secondary trauma have been initiated at organizations across the nation, including U of U Health. (3, 4)
CONCLUSION
No single strategy exists to ensure recovery from occupational trauma. It is important to talk to peers while not minimizing the events and stresses experienced. The doctor in the opening case was lucky鈥揾er hospital had a system in place to proactively reach out to physicians involved in medical errors and pair them with peers for support. As a result of her involvement in a root cause analysis of the event, she was able to help redesign the medication administration procedure in the ER to improve recognition of allergies. While she still thinks of the event when she places medication orders, she was able to use a well-developed peer support network and create positive change at her hospital.
REFERENCES
- (NEJM 1984) David Hilfiker鈥檚 landmark article is 34 years old, but it still resonates due to its blunt acceptance of the inevitability of making serious mistakes as a physician.
- (The BMJ 2000) Today's belief that constructive intervention with respectful empathy can prevent future errors stems from Albert Wu's identification of the second victim phenomenon: "The doctor who makes the mistake needs help too."
- (Eval Health Prof 2012) Seys et al conduct a systematic literature review of the second victim concept, identifying the steps necessary to support providers and make improvements after adverse events occur.
- (Patient Education and Counseling 2012) Natalie May and Margaret Plews-Ogan research the way that physician discussions about medical errors are associated with the ability to recover.
- (JAMA Surgery 2012) Hu et al argue that, despite the prevalence of stressful experiences and the desire for support among physicians, established services are underused 鈥 and that peer support is the most effective way to address the issue.
RESOURCES
CONTRIBUTORS
Brian Flaherty
Pediatrician and Assistant Professor, Department of Pediatrics, Division of Pediatric Critical Care, 麻豆学生精品版
Megan Call
Licensed psychologist, Associate Chief Wellness Officer, Director of the Resiliency Center, 麻豆学生精品版