After medical error: Care for the caregiver

Last year at a conference on family-centred care, I heard about the emotional anguish nurses and doctors experience after making unintentional medical errors that cause harm.

“How do people come back from that?” I asked colleagues of mine. “Some don’t,” I was told. “They leave the profession.” Others were so full of guilt, despair and self-doubt that they couldn't sleep for months. Some experienced post-traumatic stress disorder.

Then I read about Kimberly Hiatt, a seasoned critical-care nurse at Seattle Children’s Hospital who accidentally gave a fragile baby 10 times too much medication in 2010. The baby died five days later – though it was unclear if the error had caused her death. It was Hiatt’s first serious medical mistake in an exemplary 24-year career. She was escorted from the building, fired, and seven months later, devastated, according to her family, took her life.

While progress has been made in investigating adverse events to make healthcare safer, and in supporting the patient and family, little attention has been paid to the experiences of frontline clinicians.

“Health-care workers are often impacted by medical errors as ‘second victims,’ and experience many of the same emotions and/or feelings” as the patient and family members, write the authors of an editorial in the January 2 issue of the British Medical Journal on Quality and Safety.

Yet supporting staff hasn’t been the focus of how hospitals respond to errors.

"Everyone who'd been involved left the hospital," recounts Dr. Gary Brandeland, a family doctor writing in a 2006 Modern Medicine blog about his patient who died during a C-section because of a fatal anesthesia error. "I looked out the window, and saw nurses who had been in the OR literally running to their cars to escape the horror of what had just happened. The senior OB who had performed the C-section disappeared. I was just the first assistant...Not surprisingly, no one from the hospital administration, the nursing staff, or the medical staff including the operating OB, wanted to join me" in telling the family of the accident. "I was told by several people, 'You're the family doctor, it's best if you speak to them.' I walked in alone."

In a 2011 study published in the Polish Archives of Internal Medicine, 60 per cent of 350 health-care workers at Johns Hopkins Medicine could recall an adverse event in which they identified themselves as a ‘second victim,’ and more than half experienced anxiety, depression and concern about their ability to do their job.

"Most harm from medical errors results from bad systems, not bad people," write the authors of a 2011 white paper on Respectful Management of Serious Clinical Adverse Events by the Institute for Healthcare Improvement (you need to register at IHI to view this document). "Many health-care organizations have learned that, in the aftermath of a clinical adverse event, they could fire all the staff involved and it would do nothing to improve safety or prevent a similar event from happening again."

“We typically want to find the broken parts, fix them, remove them, and make sure that they can’t contribute to failure again,” writes Dr. Sidney W.A. Dekker in an April 2010 article in The Joint Commission Journal on Quality and Patient Safety. “However, complexity theory says that if we really want to understand failure in complex systems, we need to ‘go up and out’ to explore how things are related to each other and how they are connected to, configured in, and constrained by larger systems of pressures, constraints and expectations.”

For example, in a fatal medication error in 2006 that saw Madison, Wisconsin nurse Julie Thao fired and charged with a criminal offence, a recommendation from the root cause analysis was that the hospital reduce the risk of staff fatigue by setting policies that limit maximum work hours. Thao had worked two consecutive eight-hour shifts the day before the error, finishing at 12:30 p.m., then slept in the hospital before coming on duty again in the morning. “Systems problems include an overdependence on people being perfect without systems that support their humanness," says Jim Conway, a senior fellow at the Institute for Healthcare Improvement and an author on its adverse events white paper.

Paul Levy, former president and CEO of Beth Israel Deaconess Medical Center in Boston wrote an interesting blog about the reaction of families to medical errors: Do patients want to punish? “The literature on the topic of disclosure and apology suggests that patients and families are not interested in having the doctor or nurse be punished when a medical error occurs, if (and this is an important if), the clinician makes clear that he or she is clearly regretful about the error, is empathetic with the patient, and if the clinician and hospital show that they plan to learn from the error to help avoid repeats with other patients."

I asked Conway what parents of children with disabilities and chronic health problems need to consider about medical error. “The first thing is if they see something in their child’s care that doesn’t look right, say something,” Conway said. “Ask questions. For family members who sit on advisory committees that examine medical errors, focus not on ‘Who did it?’ but ‘What happened?,’ ‘Why did it happen?’ and ‘What’s being done to prevent it from happening again?’"

The IHI white paper says immediacy, transparency, apology and accountability are the hallmarks of a strong crisis response to medical error, and should focus, in this order, on the patient and family, frontline staff and the hospital.

An evidence-based Care of the Caregiver safe practice released in 2009 by the National Quality Forum includes five rights of caregivers following unintentional errors. They include: treatment that is just; respect; understanding and compassion, including a formal process led by an administrator to invite co-workers to express understanding and compassion to those directly and indirectly involved; supportive care – where staff are considered as patients requiring immediate and ongoing care; and transparency, where staff participate in the investigation and analysis of incidents.

As noted in an article by Dr. Charles Denham in the April 2010 Joint Commission Journal on Quality and Patient Safety: “When (Wisconsin nurse Thao), still an employee, went to the hospital pastoral care service, her co-workers were invited to come and console her. Instead, she and her co-workers reported that their nursing supervisor came to the department and ordered her physically off the property, forcing her nursing colleagues to console her, sobbing and exposed, outside on a sidewalk. Was this respect and compassion – or cruelty?”

The top five supports for ‘second victims’ of medical errors identified in the Johns Hopkins study were: prompt debriefing; an opportunity to discuss ethical concerns with the event; the ability to discuss how similar events can be prevented; timely information about the processes that take place after an event has occurred; access to counselling, psychological or psychiatric services; and formal emotional support.

There are excellent resources available online: Medically induced trauma support services includes a downloadable toolkit for supporting clinicians.

What do you think?