Patients are not the only victims in medical errors

In November 1999 (the same month the Institute of Medicine released its famous report, To Err Is Human: Building a Safer Health System), at the age of 37, I was scheduled for a total ankle replacement surgery at a major medical facility in Boston. Instead of waking up with a new ankle, I awoke several days later to discover that moments after the administration of a popliteal fossa nerve block with bupivacaine, I suffered a grand mal seizure followed by cardiac arrest. I remained unresponsive even after 15 minutes of interventions by the code team.

Luckily, many things were in place that made it possible for my life to be saved. The orthopaedic operating room (OR) team was able to take me across the hall to a cardiac OR that was prepped for another patient. The cardiac surgeon performed a sternotomy for an emergent cardiopulmonary bypass. Eventually, I made a full recovery.

The incident had a profound effect on my family, my friends, and me. I also was exposed to a side of health care most patients and families do not see. I witnessed the emotional impact the adverse event had on my orthopaedic surgeon, the anesthesiologist, code team, and other healthcare providers. It wasn’t just business as usual for them; they suffered, too, and found themselves as unsupported as my family and I were. I knew something had to be done.

MITSS
I founded MITSS (Medically Induced Trauma Support Services) in June 2002. Our mission is to support healing and restore hope to patients, families, and clinicians following adverse medical events.

MITSS has been raising awareness and educating healthcare consumers, professionals, and organizations about the emotional impact of adverse events and the need for support services since its inception. It provides direct support to patients and families as well as individual clinicians. As an organization, MITSS has advocated for healthcare institutions to build their own infrastructures to support their staff.

I was extremely naïve at the onset of this work; in fact, it turned out to be far more complex than I had ever imagined. Hospitals were struggling with acknowledging that these events happen, let alone offering those most vulnerable the support they might need. Although MITSS, as an organization, wants everyone to receive support services following an adverse event, this article focuses on clinician support.

The most important thing I discovered is that we all have a story, whether we are, a patient, family member, or a clinician. We all have a story of medical harm that has had an impact on us. I continue to be amazed at how many physicians, nurses, pharmacists, and other healthcare professionals tell me about their personal stories after I have shared mine. What I find extremely sad is how few have ever told anyone else, except maybe their attorneys.

David Hilfiker, MD’s article, “Facing Our Mistakes,” published in the New England Journal of Medicine in 1984, chronicles a medical error that he made and its aftermath. In an interview several years later, Dr. Hilfiker said that he received about 150 letters from other doctors who had similar experiences. They thanked him for bringing the topic into the open. But, it took another 10 years before others began writing about and studying the emotional impact to physicians and clinicians following medical errors and unanticipated outcomes.

What was intuitive to many was not so intuitive for others; they needed the data. In the 1990s, study of the emotional impact on physicians and other clinicians involved in adverse events began. In early 2000, Albert Wu, MD, wrote an article that doctors who make mistakes need support, too. In his article, Dr. Wu coined the term “Second Victim,” which refers to the clinician at the “sharp end” of the error. But, again, several years would pass before dissemination of the data would result in implementation of actual support programs.

Barriers to change
Several barriers—including some that stem from the culture in medicine and the way that medical education works—prevent this kind of change. The current system expects physicians to be perfect, almost “Super Human.” Clinicians who have made a medical error often say they feel that their colleagues are judging them, thinking them to be incompetent. They sense a distancing between themselves and their colleagues. This may be likely given the natural inclination to avoid someone when you just don’t know what to say.

The barrier most frequently cited is the medical-legal issue. The standard message put forth by risk managers and lawyers has always been “Don’t talk to anyone!” Recently, though, there has been a movement toward “Don’t talk about the facts of the case, but you can talk about your feelings.”

Finally, we have yet to acknowledge the emotional discomfort or educate physicians on normalizing the emotional impact around these events. Rick van Pelt, MD, the anesthesiologist involved in my case, elaborated on some of these points from a physician’s perspective in his article, “Peer support: Healthcare professionals supporting each other after adverse medical events.” The article outlines Dr. van Pelt’s personal and professional experiences that led to the implementation of a Peer Support Program at Boston’s Brigham and Women’s Hospital.

I have personally witnessed a shift in culture over the last 10 years. Dr. van Pelt and I spoke at the National Patient Safety Foundation Congress in 2004; it was the first time we had shared our personal journey on a national stage. It was also the first time that many audience members saw a physician and a patient come together for the common good of other patients, families, and the clinicians involved in a medical error or adverse event.

The feedback was overwhelming; however, the message we received at that time was clearly “You’re doing great work (but, we don’t need it).” Over the years, the feedback changed to “We need to think about support for our clinicians,” and now “Can you help us implement support services for our clinicians?”

Back in 2002, a literature search on physician/clinician support would turn up very little. Today, that same search would yield a tremendous amount on the subject. Physicians are more willing to speak more publicly about the emotional impact of these events. This, in turn, conveys a quiet, but critical, permission for others to speak.

Linda K. Kenney is the founder, president, and executive director of Medically Induced Trauma Support Services (www.mitss.org).

References:

1. MITSS (Medically Induced Trauma Support Services)—www.mitss.org
2. Hilfiker :. Facing our mistakes. N Engl J Med 1984;310(2),118-122.
3. Wu AW: Medical error: The second victim: the doctor who makes the mistake needs help too. BMJ 2000;320:726-727
4. Carr S: Disclosure and apology: What’s missing? Advancing programs that support clinicians. November 2009. Report can be accessed at http://www.mitss.org/MITSS_WhatsMissing.pdf
5. Van Pelt F: Peer support: Healthcare professionals supporting each other after adverse medical events. Qual Saf Health Care 2008;17(4):249-252.