Kimberly Hiatt made a mistake. A skilled nurse, with 24 years of experience, she was working in the cardiac intensive care unit at Seattle Children’s Hospital when, in September, she overdosed an 8-month-old patient with calcium chloride. It was an accident. The patient died. Nurse Hiatt reported the event to her colleagues at once. Of course she suffered professionally from the incident and while details surrounding the episode remain in dispute, Kimberly Hiatt was facing an investigation. She committed suicide.
Kimberly Hiatt worked in a large, highly-regarded medical facility, surrounded by fellow health professionals. Yet she clearly felt alone and keenly, personally responsible for the tragedy. An adverse event is a health care-associated harm or injury. And adverse events like this one occur, far too often, and most experienced clinicians have been part of one, at least. Patients are, of course, always the first victims of an adverse event – but they aren’t the only ones.
When patients are harmed, the clinicians closest to those patients are often devastated. A few heath care workers might take a comfort in reminding themselves that the number of patients helped every day far, far exceeds the number of those hurt. Or they blame the system somehow. But most blame themselves. In fact, patient safety expert Alfred Wu, M.D., M.P.H., created the term ‘second victims’ to describe the emotional trauma of the physicians, nurses and others connected to these events. The health care providers exhibit anxiety, depression and shame to such a degree that they, too, are wounded.
Here’s how Dr. Wu describes the beginning of second victim syndrome in an article in the British Medical Journal:
Virtually every practitioner knows the sickening realization of making a bad mistake. You feel singled out and exposed – seized by the instinct to see if anyone has noticed. You agonize about what to do, whether to tell anyone, what to say. Later, the event replays itself over and over in your mind. You question your competence but fear being discovered. You know you should confess, but dread the prospect of potential punishment and of the patient’s anger. You may become overly attentive to the patient or family, lamenting the failure to do so earlier and, if you haven’t told them, wondering if they know.
Is there anyone who can’t relate to this description? In any field or profession?
Here we are, in an advanced, rich society, blessed with abundance and plenty of every nature, and yet we cannot escape our ‘name, blame and shame’ mentality. We do it to ourselves, then to others. It’s better in some areas, to be sure, but it’s not gone. When things go wrong – and they will – if we don’t torture ourselves about it, we immediately look about for someone (that is, someone else) to blame. This would be great if it worked, if it kept patients safe and strengthened and supported those helping them. It does not.
For many years now, according to experts, including Dr. Carolyn M. Clancy, Director of the Agency for Healthcare Research and Quality, patient safety advocates have promoted a culture of safety that focuses on the role and responsibility of systems while de-emphasizing blame. The goal is to install reporting mechanisms so that patient safety events – health care-related injuries associated with the process and structure of the care itself, rather than with a patient’s underlying or physiological or disease-related condition – are reported in an anonymous, safe environment. Near-misses are included, too. The object of the exercise is to learn from all the events, to understand what went wrong, and how, and to prevent future injuries.
How is this working out? There is no doubt that systematic reporting is vital to improving patient safety. Health care providers, however, are still grappling to balance this approach with the real need to correct individual behavior where necessary. Many clinicians still regard any patient safety events as personal failings.
Second victimhood is far more common than we realize. This internalized judgment becomes a self-inflicted emotional wound, according to many experts, and then along comes the review and judgment of an oversight body (such as a nursing board). The internalized self-criticism is thereby reinforced. Consider Kimberly Hiatt’s heartbreaking situation. Oversight bodies are an indispensible part of a safe, effective health care system, but more than a few clinicians feel singled out, even persecuted, by such bodies.
Are there arrogant, indifferent doctors out there? Yes, absolutely. Are there distracted nurses and ill-trained techs? Undoubtedly. But most of our practicing physicians, nurses, NPs, PAs and other health care professionals are dedicated, compassionate and well trained team players committed to their patients, committed to good outcomes. And they are people, not machines – just like the rest of us. You want smart, thoughtful, loving people taking care of you when you’re ill, not robots. Correction they may need from time to time – relentless pressure to be perfect not so much.
Soaring health care costs are all but overwhelming this country. Millions of Americans are without access to even basic care. There are astonishing medical advances and breakthroughs out there we soon won’t be able to afford. Our soldiers and veterans are suffering lifelong consequences of their service, our politicians are arguing about everything, our aging population is vulnerable and threatened, and chronic disease and condition rates may send the nation into bankruptcy. How are we not working together on all of this, each part assuming its own responsbility?
Tomorrow we will continue our look at second victim syndrome. There’s a good chance it represents more than just one of the problems of our health care system. It maybe says something about our culture in general. And if we are committed to developing a health care system that truly reflects the strength and character of this nation – and we should be – we might consider consciously moving away from ‘name, blame and shame’, towards a more enlightened approach.