Tuesday, January 3, 2012

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?


Louise, you hit a home run with this post...

I think care for the caregiver in all situations is the most moral and humane thing for hospitals to do - including after disclosing a diagnosis, after a patient dies, after an adverse event - after any difficult situation. I hope others can share examples of initiatives out there that support staff and physicians.


My husband is an investigator on our state's medical review board, and he says while some of the mistakes he investigates are due to doctors being jerks or generally just not listening to the patients, lots of them are simply human error - and that the people involved feel terrible about it.

The comment in the article that we need to ask "why did this happen" is important - are doctors and nurses working too many shifts in a row? Are they understaffed so don't have the time to really review a chart? Doctors are human, and mistakes are going to happen. But the administrators have to do everything they can to minimize the possibility.

Hi Sue -- Thanks so much for your message and for pointing out other difficult clinical situations where support for staff is crucial. If that support is not there, how can staff be expected to be emotionally present and open to patients and families in their worst times? If staff don't have models for providing empathy and comfort, how can they continue giving it to families? They need to be fed first!

Thanks also for your lovely card. Happy New Year! Come visit us at Holland Bloorview again soon! xo

Hi Amy -- Thanks so much for your message and sharing your husband's experiences. I'm sure his job is an eye-opener. You're right -- medicine is the only profession where perfection is expected.

Welcome to BLOOM and I would love to hear more about your girls? Send me your snail-mail address and I'll put you on the mailing list to get the BLOOM magazine (lkinross@hollandbloorview.ca) Thanks!

As a patient who has experienced medical errors my experience did not follow those important ifs Paul Levy identifies.
I have some sympathy for the medical staff, but their feelings don't seem to come close to those of the people and families who must live with the effects of their errors.

Dear Anonymous -- thank you for your comment. I agree that the prime focus needs to be the affected patient and family, and that staff are impacted in a secondary way. I remember a surgery that my son had that in the end was not successful because of a complication resulting from an infection. I had brought him in to emerg a number of times and called the resident on call because I was concerned, and I felt I wasn't taken seriously. When we found out about the damage and I questioned the surgeon about it, he said: "We all feel terrible when things like this happen." And I thought "No. I'm sorry, but you don't feel the way I do." I do think it's important to keep the focus on the the experience of patients and families, while recognizing that staff also need support.

As a family that experienced two major medical errors in 2010 (one causing permanent brain damage to my just-born daughter), I can see both sides of this. Family and clinician are caught in the crossfire of a system that's not designed to facilitate the tough kinds of discussions it takes to 1)prevent medical errors 2)embrace learning from them 3)have an open dialogue among ALL parties involved. Imagine the difference of 100 per cent transparency right away among all of those affected. The most important aspect is listening to the clinicians, the family/patient and then using that to change or improve policy and procedures and then updating all participants of that progress. In addition basic communications is needed to help people through the psychological, physical and legal aspects (when applicable) so that as time passes by there is more understanding among everyone. Administrators have long been advised by lawyers to keep quiet and that's the wrong advice. The University of Michigan Hospital has a good model for this, not perfect but better than most when it comes to transparency. I feel sorry for the people involved and don't blame them, but I do see poorly designed health care system that's not helping them as much as it could.

Hi Tim -- I really appreciate you posting here. I don't think I knew about the medical errors your family had experienced, and I can't fathom the impact of the one you describe.

Do you feel that changes were made following these medical errors that made it less likely that they would occur again?

Was there transparency in how you were told about the incidents?

Perhaps you can write a post for us about it.
Hugs to you and your girls xo

Thanks for a great post, Louise. I know many people, including myself who have suffered from medical error in their families. I think it is important for patients/families to understand the devastation some providers feel and also to understand how complex medicine is and how easy and unintended or subconscious error can occur. When most people make a mistake they say, "oops, sorry" and no big deal, but in healthcare, that "oops" might be someone's life.

I think that full disclosure (including ALL records) is critical. Also, an apology by administrative staff is not a substitute for an apology by the staff. A face to face meeting with the provider(s), with both sides adequately prepared, provides the best opportunity for apology and forgiveness, both which are necessary for both sides to heal.

Dear Anonymous -- thanks so much for posting.

Great recommendations in your second paragraph.

Were these conditions met in the cases of medical error your family experienced?

Best wishes, Louise

Louise - the short answer is 'no' I don't think changes were made and there was simply no transparency with the first mistake and minimal with the second one (a drug overdose the caused the need for Gwen's trach). It was really a missed opportunity for the hospital to learn from my family and embrace us to advance its patient-centered care efforts. I'd be happy and honored to write a post about this for you!

I had a hard time reading this as my family has suffered medical error, twice, which ended in tragedy.

I know that in at least one instance, there was a second victim who was emotional about what had happened. I was however shocked and appalled when the second victim, was able to keep her job, was told she didn't really do anything wrong and when we were told that we had to act like it didn't happen to protect the second victims name.

I cannot prove this, but sometimes if I am at appointments with client and the health professional talks about my client, they sometimes talk as if it is okay to do any procedure, because the child has a disability. I have heard "it's not ideal for most people, but let's try it" way too many times. These are always extreme trials when there are other options. Do children with disabilities get succumbed to more things because they can't tell us of their pain? Who knows, I just wish people would be held accountable, but there definitely needs to be compassion for both victims!

Hi Marjorie -- I'm so grateful you posted this comment.

And I know your story and can't IMAGINE living through that and feeling that the need to protect the clinician's name came before accountability for the hospital.

Also - you make a very good point about how sometimes clinicians seem to be willing to do almost any procedure on a kid with disability. I know in our experience sometimes the response is "we might as well try' when really there isn't great evidence that it will be beneficial. I also think that it would be useful for surgeons to spend significant time on an inpatient floor like Holland Bloorview's to truly understand the rehab process.

As a parent of a child who has significant cerebral palsy and profound deafness caused by medical error, it is so extremely difficult to "see the other side". Our son had simple jaundice that went untreated in a level three highly experienced NICU, and this is what caused his disabilities. I think what infuriates us the most is that in our son's situation, his condition was 100% preventable, and was so simple to treat. The nursing staff was extrodinary, and brought their clinical concerns forward, but they were not given the appropriate attention by an arrogant, overly confident attending physician, who was more concerned with making sure he was tending to his residents first. To make matters even worse, we learned of another family who went through the same trauma a year or so after our son, at the same hospital. That left 2 families forever changed.
We chose to seek legal action in an effort to ensure that this never happens to another child again at his institution, and to help us provide the necessary resources that our son will need for his future care. And although going through legal proceedings has added another layer of stress to our already stressful life, we felt that we needed to do so to try to right the wrong in some respect.
I do feel for the care staff that have been brought into this process, because for many of them, they were just in the wrong place at the wrong time, but our son is our first priority, and there are too many medical professionals out there who do not always do the right thing for their patients.