Supporting clinicians after medical errorBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1982 (Published 15 April 2015) Cite this as: BMJ 2015;350:h1982
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Medical errors : To err is human, but it mustn’t be deliberate, by ignorance, neglect, or due to unwarranted haste, etc.
No doctor would ever want his or her patient to suffer, even if it happens inadvertently. But mishaps and medical errors do happen, and as such they do not reflect upon the competency or experience of a doctor. We all are humans, and inadvertent errors can occur. We need to recognize them, and the society by and large must also see it as such and accept it. We strongly believe that the best way to face it is by being open and honest; and face all of it squarely. For this, we all must be supportive to each other, and must not let any remorse, fear of persecution, victimization, intimidation, or depression to set in. It would be a different story if somehow the errors are seen not to be happenstance, or are believed to be caused by ignorance, neglect, deliberate, or due to unwarranted haste, etc.
We would also like to add that It will possibly go a long way if we say sorry, even if one is not responsible for whatever happened. The administrators and senior colleagues have to remain supportive, to the extent justified, and all loose talks and conjectures by anyone amongst the staff and colleagues must be snubbed out effectively. All investigations and inquiries should be fair, thorough, and transparent. It should be ensured that they are wrapped up within a shortest stipulated time, thereby preventing any chances of further anxiety, or in any inadvertent pressure that might produce a ‘second victim’. While at it, the society and policy makers must also involve themselves in doing some serious introspection about the impact of the fear of litigation and of protracted legalities, and their consequences and impact on the practice and performance by medical practitioners, and whether or not it is the time for some changes that might be helpful to the patients and can also prevent the rising numbers of ‘second victims’.
Dr (Lt Col) Rajesh Chauhan
Honorary National Professor, IMA CGP, INDIA.
Dr. Harendra Kumar Gupta
Hon' Professor IMA CGP & ex-Dean IMA CGP, INDIA.
Competing interests: The views expressed are those of the authors, and do not reflect any official policy or position of any organization or association.
The “second victim” phenomenon can be devastating for individual clinicians, but it also has serious implications for patient safety and safety culture, so responsibility for recognizing and addressing it goes well beyond individual clinicians and their employing organizations.
“Second victim” experiences are directly affected by the manner in which incidents are dealt with and investigations conducted; they will be worse in clinicians who have negative experiences of investigations or who feel that they have been dealt with in a punitive manner. Such clinicians become less likely to report future incidents or to practice transparently, and if they are senior then their attitudes will influence the behavior of more junior staff (1).
A Royal College of Physicians survey of 1755 senior NHS physicians reinforces findings of previous work in other groups (2). Most had been involved in serious adverse events and most had experienced the sorts of “second victim” effects described by Edrees and Federico; 60-75% described sleep disturbance, anxiety or stress and a small but significant percentage described effects similar to Post Traumatic Stress Disorder. Although most had used formal incident reporting systems only a minority described positive feedback or useful learning; 25% admitted being involved in incidents which they knew they should have reported, but didn’t. Factors contributing to this included a belief that nothing would change as a result of reporting, fear of punitive action and the psychological effects of having been involved in a previous adverse event.
Few physicians have formal sources of support after incidents; most turn to friends and colleagues as only 5% have a formal mentor. However, 80% of respondents describe a determination to improve as a result of an adverse event suggesting that in the right circumstances they could be engaged in a learning process.
The NHS is still a long way from the open, transparent, safety culture that we need (3) and this will only be achieved if we recognize and address the “second victim” phenomenon. We would caution against characterizing this as only due to “clinicians unable to cope with their emotions after a medical error” although we recognize the importance of providing support, including mentoring, to individual clinicians. However, since the attitude and behavior of policymakers, regulators, those managing reporting systems and other external bodies can be part of the problem then these bodies must also take responsibility for being part of the solution.
1. Sirriyeh R, Lawton RJ, Gardner P. et al. Coping with medical error: A systematic review of papers to assess the effects of involvement in medical error on health care professional’s psychological well-being. Qual Saf Health Care 2010; 19: 1-8.
2. Harrison R, Lawton R, Stewart K. Doctors’ experiences of adverse events in secondary care; the professional and personal impact. Clinical Medicine 2014 Vol 14, No 6 (Dec 2014) 585-90.
3. National Advisory Group on the Safety of Patients in England. A promise to learn—a commitment to act. Department of Health, 2013.
Competing interests: No competing interests
It was with great interest that we read your editorial on “second victims” in this week’s BMJ. The concept of “second victims” as described seems to revolve around medical error and the psychological consequences of these events on the clinician.
The usual duties of a surgeon meet Criterion A of the Diagnostic and Statistical Manual version 5 (DSM 5) for post-traumatic stress disorder (PTSD) and acute stress disorder (ASD). There is an expectation that surgeons will be entirely habituated to this “run of the mill trauma” and that they will continue to deliver care in spite of preceding events.
Specialist training in surgery is known to be a stressful experience in which efficient and accurate learning is key to success. The symptoms of PTSD/ASD disrupt sleep, mood and concentration. Clearly, PTSD/ASD amongst trainees is likely to be harmful to learning.
We agree that future studies should focus on organisational culture as well as the willingness of individuals to access support services. We would argue that waiting for error as a trigger rather than signs of stress, may have the unintended appearance that support is punitive or stigmatising. Using a validated scoring system  we aim to understand the prevalence of PTSD/ASD type symptoms within surgical trainees, current approaches to supporting them and their uptake.
This study will take the form of a web based survey, the link for which is below. The results so far have been fascinating. Of 120 respondents 42% report that their training has suffered due to PTSD/ASD symptoms but only 15% have received any support. We would be grateful if any surgical (pan-specialty) trainees reading this rapid response could participate.
1. American Psychiatric Association DTF. Diagnostic and Statistical Manual of Mental Disorders: DSM 5. 5 ed. Arlington, VA: American Psychiatric Association, 2013.
2. Lazarus A. Traumatized by practice: PTSD in physicians. J Med Pract Manage 2014;30(2):131-4
3. Weiss D, Marmer C. The Impact of Event Scale- Revised. In: Wilson J, Keane T, eds. Assessing Psychological trauma and PTSD: a practitioner's handbook. New York: Guilford Press, 1997:399-411.
Competing interests: No competing interests