The ‘second victims’ of clinical error
In my first year in practice, I worked in a very busy clinic which also acted as an emergency centre after hours, at the time one of three large emergency clinics in Melbourne. Among the enormous number of cases, I made some great clinical decisions but also some howling errors. Two immediately spring to mind. The first was a white kitten bleeding from around a tooth which I attributed to the fact that it was losing its deciduous teeth, but was due to eating Ratsac (a Vitamin K antagonist), a realisation which hit me about an hour later. I rang the owners, who brought the kitten back and it recovered with treatment. The second was a cat brought in unable to move its hind limbs. I initially assumed it had been hit by a car but it had a saddle thrombus secondary to cardiomyopathy. I remember noticing during the consult in some distant corner of my mind that its hind paws were cold but it wasn’t until I was positioning it for a pelvic radiograph that my neurones connected the cold paws and paralysis and I proceeded to work it up and treat it for thromboembolism and cardiomyopathy. The fact that I still cringe at my clinical blindness and recall minute details of both cases 15 years later illustrates the impact they had on my psyche. I was ‘the second victim of the error’, a phrase coined by Professor Albert Wu1 to describe the impact of errors on clinicians, nurses and other support staff.
I have previously written about cognitive aspects of diagnostic error. Brian Goldman’s TED talk, ‘Doctors Make Mistakes. Can we talk about that?’2 (thanks to Jan Ehlers for the link) discusses errors from a clinician’s perspective and reminded me that my fear of errors contributed to my decision to move away from practice. I have only ever admitted that to others who I know share my anxiety because in some way I am still ashamed. I will never make those mistakes again.
After listing some of his own errors, Goldman, an emergency physician well-known medical journalist in Canada, talks about striving to be a perfect and resisting asking for help for fear of being seen as high maintenance. In the aftermath of an error, he recounts thinking, ‘make the voices (in his head) stop and don’t let me make another mistake’. I related completely.
Goldman feels that the culture of silence around error is a major contributor to the feelings of shame and isolation a clinician may feel after making a mistake. Albert Wu agrees, stating that ‘confession is discouraged, passively by the lack of appropriate forums for discussion and sometimes actively by risk managers’.1 This culture has been attributed to the ‘hidden curriculum’ in medical education – the messages and attitudes transmitted through day-to-day attitudes, actions and vocabularies.3
Failure to support the emotional needs of clinicians after an error can have significant consequences such as poorer patient care, depression, burn out, premature retirement4 or, in particularly tragic cases, even suicide5. Wu notes that …’some of our most reflective and sensitive colleagues [are] perhaps most susceptible to injury from their own mistakes’1, a category I feel I fit into.
At a personal level, strategies to support colleagues after errors may include encouraging a description of what happened, affirm rather than minimise the importance of the mistake and disclosing your own mistakes to help reduce the sense of isolation. Acknowledge the emotional impact of the mistake and ask how the colleague is feeling.1 At a broader level, Goldman suggests better systems to reduce errors and rewards for identifying errors and for coming forward after an error has occurred.2
In my experience, a similar culture of silence around clinical error exists in veterinary practice. I shared my mistakes with close friends, who were extremely supportive and, as new grads, also had their own stories. Systems for coping with errors were never mentioned during my veterinary education. There is now rightly a far greater focus on mental health of veterinarians and much better support, for example through the Australian Veterinary Association, although I could find no mention of clinical error in their VetHealth section. I would be very interested to hear of any specific veterinary examples of support for veterinarians or veterinary nurses after an error has occurred or systems to help us learn from errors.
Where there are clinicians and medical and veterinary support staff there will always be errors. The second victim is also important.
- Wu AW. Medical Error: the second victim. BMJ. 2000; 320(7237): 726–727.
- TED. Doctors Make Mistakes Can We Talk About That? http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that.html. 2012. Retrieved 8 February 2014.
- Liao JM, Thomas EJ, Bell SK. Speaking up about the dangers of the hidden curriculum. Health Aff 2014; 33(1):168-171
- Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser V, Gallagher TH. The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada. Joint Comm J Qual Patient Saf 2007; 33(8):467-76
- NBC News. Nurse’s Suicide Highlights Twin Tragedies of Medical Errors http://www.nbcnews.com/id/43529641/ns/health-health_care/t/nurses-suicide-highlights-twin-tragedies-medical-errors/#.UviuNfmSySo. 2011. Retrieved 10 February 2014.