by Blair Hickman, ProPublica | Jan. 25, 2013, 11:50 a.m.
Dr. David Ring, an associate professor at Harvard Medical School and board certified orthopedic and hand surgeon, once performed the wrong surgery on a patient’s finger. Ring quickly noticed and fixed his mistake, but it was one of the worst experiences of his life, he told ProPublica reporter Marshall Allen in a 2011 interview.
Sometimes doctors or nurses who cause harm to a patient are the perpetrators: They’re careless, negligent, taking on too many cases because they’re greedy, sloppy or incompetent. But often this is not the case. A well-meaning, expertly-trained provider makes an honest error and feels deep remorse.
Plus, there are often extenuating circumstances that contribute to the mistake. In Ring’s case, a series of events contributed to confusion in the operating room that day. As Allen noted:
- The nurse marked the correct arm, but not the incision site.
- Surgeons were behind schedule, so people were stressed.
- The nurse who prepped the patient for surgery wasn’t present for the procedure, because the patient had been moved to a different operating room.
- The nursing team changed in the middle of the procedure.
In these cases, health care providers, like Ring, are sometimes called the “second victim” of medical mistakes. The term recognizes that being part of an error also takes an emotional and psychological toll on the provider. According to Susan D. Scott, a registered nurse and patient safety coordinator at the University of Missouri Health Care, providers have described, in published anecdotes, “powerful feelings of guilt, incompetence, or inadequacy:” feelings that can affect performance and, in some cases, have destroyed careers.
Members of ProPublica’s Patient Harm Community have criticized the term “second victim.” Debra Van Putten called it “deeply offensive and insensitive to the patient community.” Bart Windrum said, “I actually almost abhor the phrase “second victim” describing providers. I understand its impetus, it’s just wholly inaccurate because the family members are the 2nd victims. Providers are at best 3rd victims.”
Many providers stay quiet about errors, which complicates the issue. Some fear a ruined reputation. Some are wary of bullying from colleagues. Some feel pressure from hospital lawyers and risk managers not to admit to mistakes.
But Wu is among those who believe that recognizing the phenomenon and changing medicine’s culture of silence could help doctors heal and benefit patients, too.
“If people are consistently beaten up when there’s a bad outcome, you create a climate in which no one talks about anything,” Wu told Health Leaders Media’s Cheryl Clark, “and a conspiracy of silence leads to mistakes being repeated.”
Brian Goldman, an emergency room physician in Toronto, echoed Wu’s thoughts in a TED talk in November 2011: “If I can’t come true and talk about my mistakes, how can I share it with my colleagues? How can I teach them about what I did, so they don’t do the same thing?”
Doug Wojcieszak, a member of ProPublica’s Patient Harm Community, also believes transparency can help reduce lawsuits over medical errors. Wojcieszak’s brother died after a mistake in 1998. Now, his organization, SorryWorks!,encourages and trains health care professionals to rapidly disclose errors, conduct independent reviews and, if necessary, apologize and negotiate financial compensation with patients outside of the courts. The University of Illinois at Chicago Medical Center has experimented with disclosure as part of a program Allen wrote about three years ago.
Wojcieszak said providers have also told him that disclosure is one of the best ways to aid personal healing and learn from mistakes. “The organizations that are really good at this will tell you that the biggest benefit is patient safety,” he said. “When we own our mistakes, we have a chance to learn.”
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