Download a PDF of the Current Issue 2015 Volume 12 Number 3 July- September

Second Victims: To Forgive, Divine.

By Francys C. Martin, Esq. Claims and Litigation Coordinator
UF HSC Self-Insurance Program
9-4-2 Alexander Pope, an 18th-century English poet, wrote in part, “To err is human; to forgive, divine.” Forgiveness can come from very many different sources, but the ability to forgive oneself is often the hardest to come by. Mistakes are a human inevitability. As a result of studies such as “To Err Is Human”, increased media attention to medical errors, and organizations like the National Patient Safety Foundation and Leapfrog Group, patients have become savvy consumers of their own healthcare which should stand to benefit everyone involved in promoting patient safety and error prevention. Facilities across the nation have answered the call, promoting a culture of safety, and encouraging reporting of patient safety events so that all healthcare providers can learn from errors and adapt when necessary.   One recent article colorfully entitled “How to Stop Hospitals from Killing Us” provided a number of thoughtful ideas on increasing the transparency of healthcare1.  One of the central themes of this article was that, “To do no harm going forward, we must be able to learn from the harm we may have already done.”2 No one is more integral to that lesson than the healthcare providers involved in that harm. While transparency is promoted to help others understand and prevent similar errors, many are not sensitive to the fact that the involved healthcare providers often feel guilt and shame, and even a sense of abandonment by their peers. Errors can sometimes have devastating consequences for all those involved and although the patient and their family may be the most obvious victims of the error, they are not the only victims.   An article by Dr. Albert W. Wu, Director of the Center for Health Services and Outcomes Research at Johns Hopkins, and a prominent voice in medical errors and the impact on providers, referenced his own experience. A colleague who committed a medical error was summarily judged and found guilty of incompetence by his peers.3    unfortunately, he also found that there was little sympathy for the resident who committed the error. His experiences and his studies of the emotions surrounding a medical error led him to the theory of a second victim. He found that what is most needed is “unconditional sympathy and support” from peers, which can often be lacking. Although support can vary among facilities, most encourage a “no blame” environment where all healthcare providers can feel free to report and discuss events without fear of retaliation or judgment.   Disclosure of medical errors and apologizing to the patient and their family for their unexpected experience is not only an ethical and legal imperative, but can contribute to the feeling that “ownership” for any error belongs to the entire facility and that the involved healthcare provider is not alone. Sharing the experience of being involved in an error with colleagues and peers is also beneficial because they realize that they are not the only ones that have made a mistake.   Thoughtful and timely disclosure can help lessen the emotional trauma to all victims of an error if conveyed appropriately. Disclosure and proper handling of grief and rage is a learned skill, therefore, prior training on disclosure is recommended for every healthcare provider. Once an error occurs and disclosure is made, healthcare providers often face the daunting task of having their error repeatedly discussed in patient safety committees, morbidity and mortality conferences, with risk managers and often with their supervisors. Where a healthcare provider has been unable or unwilling to face the error, these interactions can force them to break down the causes of the error. As Dr. Wu noted, even when these errors are discussed in a number of forums, “it is to examine the medical facts rather than the feelings of the patient or physician.”   Failing to address the feelings of the healthcare provider can lead to destructive and damaging behavior on the part of the second victim. Although there is a spectrum of emotion exhibited by healthcare providers, there are often two very concerning reactions to the error: those that care too much and those that appear to care too little. Each of these is a defense mechanism that has its place in assisting the healthcare provider in assimilating the error, but can also sometimes evolve into a dysfunctional reaction to the events surrounding them. Some healthcare providers may become defensive, blame others for their error and generally, fail to see the part they may have played in the error. They may lash out at their own colleagues, other departments or divisions involved in the patient’s care, or may even seek to find fault with the patient.   Other healthcare providers may feel the weight of the error with such force that they cannot stop re-analyzing and reliving it. These healthcare providers are often those most capable of expressing their feelings and of self-reflection. These same characteristics that make them such compassionate and empathetic caregivers, can also make them more likely to hold on to the error, as well as the guilt and shame associated with it. As a consequence, they often blame only themselves, viewing the error as a personal failure, instead of viewing their role in the proper perspective. In fact, even when granted the forgiveness of the patient or their family, they may be unwilling to forgive themselves.   The effects of an error can follow the second victim into their personal life and impair their own physical well-being. Sadness, fear, shame, insecurity and depression can be commonplace. The experience can also be protracted by organizational and regulatory investigations including investigations by their respective licensing boards. Further, if litigation is pursued, the error can remain in the forefront for years to come.   Such appears to have been the widely reported case of Kimberly Hiatt, a highly experienced pediatric nurse from Washington State, who was involved in a medication error that may have contributed to the death of an already fragile 8 month old patient in 2010. Ms. Hiatt appears to have made a calculation error that led to an overdose of calcium chloride. It has been reported that following this incident, she was terminated after 27 years of nursing for reasons unrelated to this incident. She was fined and placed on probation by her state licensing board. Seven months after the fatal error, she took her own life. It is unclear how much support she had and what other issues may have contributed to her tragic decision, but it is imperative that incidents like this which compound the tragedy of the error, never occur. This begins with recognition of the impact on second victims and the development of programs that provide an outlet for healthcare providers to share their feelings and provide emotional support to each other.   Charles Denham, chairman of Texas Medical Institute of Technology, proposes five human rights for second victims, which can be remembered by the acronym TRUST4:

Treatment that is just: Assume innocence and good intentions, and treat all parties fairly.

Respect: No blame or shame for human fallibility.

Understanding: Compassion for the grieving and healing that the second victim will experience.

Supportive care: Psychological and support services.

Transparency: Allow second victims to participate in learning opportunities and the prevention of future medical errors.

  Denham goes even further and posits the existence of a “third victim” of medical errors. The medical error itself can also wound the leaders of the healthcare facility as these leaders are placed in the difficult position of caring for all of the healthcare providers and the organization itself, even those with conflicting points of view. If handled incorrectly, the very culture of the healthcare facility can be harmed and the consequences of same could reverberate for months and years to come.   No healthcare provider intends to harm their patients and certainly, the goal is always to provide good care to patients. Under the best of circumstances, healthcare providers deal with illness and loss on a daily basis. They are by their nature, desirous of helping those who are ailing and often form an emotional connection to those patients. When there is loss, it is their loss as well. When the loss is as a result of their own error, the loss can be unbearable. Although there is a clearly defined victim of the medical error in the form of the patient, the harm can go well beyond that patient to the medical staff, the facility and the entire healthcare organization. Not all facilities are equipped to deal with the needs of its staff following a medical error. Fortunately for some healthcare providers, many facilities are mindful of the emotional and psychological toll that a medical error can take on all those involved in the patient’s care. These same facilities are instituting mechanisms to assist healthcare providers with the stress and grief caused by medical errors. The importance of second victims and the need for further research and development of a formal program was recently recognized this year through a grant awarded by The W. Martin Smith Interdisciplinary Patient Quality and Safety Awards Program which you can view at www.flbog.sip.ufl.edu.     1How to Stop Hospitals From Killing Us by Marty Makary, The Wall Street Journal, September 22, 2012. 2Id. 3Wu AW. Medical error:  the second victim. The doctor who makes the mistake needs help too.  4BMJ. 2000; 320 (7237): 726- 727. Denham, Charles. TRUST: the 5 rights of the second victim. J Patient Saf. 2007; 3(2): 107-119.