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Public Safety, Private Anguish

As we continue talking about second victim syndrome, what happens to health care providers involved in unanticipated adverse patient events, we right away come face-to-face with some pretty ugly truths about ourselves and our health care system.  Bad things, tragic things, even unforgivable things happen to patients while they are in hospitals, under the care of physicians.  There are medication errors, botched procedures, dangerous infections, patient care mishaps.  A recent study indicated that 1 in 7 Medicare fee-for-service patients experienced a serious adverse event while receiving medical treatment, while another 1 in 7 experienced a less serious but still significant adverse event.  What’s going on?

It’s difficult to feel compassion and sympathy for doctors and nurses when our ill or injured children, parents and friends are subjected to shoddy treatment or are harmed by the very same people we trust to help us.  So we get angry and feel misused, conned, victimized.  But we need to step back and look at the whole picture.

When things go wrong, it’s the rare doctor or nurse or other medical professional who doesn’t feel deeply responsible.  Emotional trauma, including anxiety, depression and shame, is far more common than outsiders may realize.  Doctors and nurses make mistakes, sometimes bad ones.  Then they start to doubt their ability to perform their jobs; they often receive little peer or institutional support.  The self-doubt and sense of isolation escalate.  Oh, they may put on brave faces and offer excuses and explanations, but while the patient is always the first victim, the caregivers are right behind them as the second victims.  It’s lose/lose all the way.  Remember Kimberly Hiatt.

Obviously, the surest way to avoid second victim syndrome is to avoid having any first victims.  If no patients are harmed, then no health care workers are in turn harmed.  But we are people, not machines – all of us.  The medical and health care world is working very hard to create a harm-free system, but in the meantime, we need to do our part, too.  There are better ways than ‘name, blame and shame’ to handle harm when it does inevitably occur.

It is firmly established that systematic reporting is critical to improving patient safety.  The Patient Safety and Quality Improvement Act of 2005 created Patient Safety Organizations (PSOs) to collect voluntarily disclosed and reported patient safety events.  Analyzed in a standardized and meaningful way, free from legal discovery, this information has already begun transforming procedures and improving patient care and safety policies.

On the subject of the second victims, researchers have identified a six-step clinician recovery process:

  1. Chaos and accident response
  2. Intrusive reflections
  3. Restoring personal integrity
  4. Enduring the inquisition
  5. Obtaining emotional ‘first aid’ and
  6. Moving on

How does one move on?  The researchers sorted three ways:

  1. Dropping out – that is, leaving health care altogether
  2. Surviving (emotionally burying the event)
  3. Thriving – learning from the event or incident in order to become a better clinician.

It is established that whether or not clinicians reach stages 5 or 6 of the recovery process, whether or not they thrive or drop out, more often than not depends on the culture of the hospital or institution where they work.  It follows, then, that health care providers who successfully advocate and support a patient safety culture help their staff members.  Those institutions that do not focus on proper patient safety may actually be harming both their own patients and their clinicians.  Again, lose/lose.

It is said that the best test of a true patient safety culture comes immediately after an event occurs.  The first instinct of the clinicians involved may be to hide it.  This is a perfectly natural first response, especially in this litigious era, but it’s the wrong thing to do.  Whatever happened needs to be disclosed at once, as counter intuitive as this may seem.  Most modern thinkers are strongly advancing disclosure, and even an immediate apology, as a means to alleviate the emotional trauma for both the first and second victims of patient safety events.

Interesting, isn’t it?  If we look at things this way, there’s no good cop or bad cop, no us against them.  It’s everyone doing their part, pulling their own weight, behaving like grown-ups.  We have a common purpose here, a common goal: a healthy, fit, inspired nation.  Maybe we need to shift away from crime and punishment and move towards mercy and redemption.  Too Pollyanna?  Too Tim Tebow?  Maybe.  Maybe not.  Certainly the present alternatives aren’t  doing us any favors.

Special thanks to Agency for Healthcare Research and Quality (AHQR), Carolyn M. Clancy, MD, Director.  

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