Much has been written about the impact of errors on patients. Most of the literature examines how they occur, the variety of ways in which they are viewed, what can be done to prevent them, and how they are disclosed. In this month's column, we examine the impact of errors on those who make them.
HYPOTHETICAL CASE
David, an experienced PA serving in a hospitalist role, is asked to manage the discharge medications for Sylvia, an oncology patient. Sylvia has a variety of postsurgical complications and is taking more than 100 mg/day of methadone and up to 100 mg/day of oxycodone. Her ongoing pain has been difficult to control, with complications including both nausea and ileus. Sylvia and her family are insistent about moving away from oral opioids completely and want to switch her to a fentanyl patch alone, an approach that they say has worked in the past.
David has performed opioid conversions many times, moving patients from patient-controlled analgesia to oral medications, and he feels confident about making such conversions. He has little experience with methadone and fentanyl patches, however, although he recently had a role in two such conversions. David is not able to contact the attending who is overseeing Sylvia's case, and staff residents seem unenthused about helping him. Third-year resident Janica says, "You know more about this stuff than I do, David. I can't help you." David attempts to contact a team pharmacist who has been helpful before in working through tricky opioid conversions, but he is not able to reach anyone from pharmacy.
David has an opioid conversion table that he frequently uses to good effect, and he has previously accessed several Web sites for help with opioid conversions. He begins by systematically going through Sylvia's current opioid regimen. Using the tools he has, he comes up with a plan to gradually move her from her oral medications and convert her to fentanyl patches completely over a period of 7 days,
Per past instructions from his colleagues on the hospital pain team, he calculates Sylvia's total opioid dose, translates it to a morphine equivalency, and figures out a comparable fentanyl patch dose. Aware that this is a potentially dangerous conversion, he checks his calculations several times. Finally, he is confident that he has arrived at the proper dose of fentanyl patch. He asks Phillip and Renita, two residents in the surgical service, to review his calculations; both say "looks good to me."
David considers delaying Sylvia's discharge until he can have his attending and pharmacy colleagues go over the case, but he is confident that his medication discharge plan is safe. Sylvia is in good spirits and pleased to be going home as she is discharged with her conversion plan.
Five days later, Sylvia develops severe respiratory depression, which worsens over a 2-day period. She is brought to the hospital on day 8, and despite efforts to reverse the opioid overdose, she dies later that day from respiratory depression related to opioid overmedication. Later that day, David is shocked when his attending tells him about Sylvia's death. His supervising physician is very upset. A review board finds that David made a significant error in estimating the morphine equivalent of methadone. This resulted in Sylvia's receiving a fentanyl patch dose almost 20 times the opioid dose she was receiving in the hospital.
WHEN THE PROVIDER BECOMES THE "SECOND VICTIM"
Significant and harmful medical errors occur regularly, but experience shows that physicians and other providers have difficulty finding support after committing the error or in offering support to fellow providers who have erred.1 This has resulted in significant emotional challenges for providers, who become "second victims."2
Waterman describes the struggles facing clinicians who have made significant medical errors. These include increased anxiety about future errors, decreased confidence in medical decision making, compromised sleep, job dissatisfaction, and harm to their reputation. Additionally, physicians consistently report a lack of resources in such settings, with only 10% noting that health care organizations provided adequate support in coping with stress related to their having committed a medical error.3
White and Gallagher note that participating in a medical error can have both short- and long-term consequences:4
Following involvement in an error, health care workers at all levels of training commonly experience a complex range of feelings, including guilt, self-doubt, embarrassment, disappointment, self-blame, a sense of inadequacy, and fear [8,9].... These emotions may persist for months or years and contribute to the already substantial stress of medical training by triggering burnout and depression [11].
PREDICTABLE POSTEVENT TRAJECTORY
In their discussion of the second victim phenomenon, Scott and Hirschinger describe the stages caregivers go through as predictable "postevent trajectories:"2
1. The first stage is described as a "chaos and accident" response, in which the clinician learns of the event and works to figure out what happened and why it transpired.
2. The authors describe the second stage as "intrusive reflections." Here, the clinician committing the error may reevaluate the scenario in an attempt to understand what happened and how it might have been prevented. This might include disturbed and haunted reenactments and rumination about what transpired, as well as guilt and shame.
3. The third stage involves "restoring personal integrity," as the clinician strives for acceptance and support from the work and social setting; this may include management of "grapevine" gossip, with mounting fear of the professional, personal, and financial damage that may accompany the error.
4. Stage 4 brings realization of how serious the event was, with continued anxiety about it and its consequences. Here, symptoms of the physical and psychosocial stress being felt by the clinician may manifest symptomatically.
5. In the fifth stage, the clinician may reach out for personal and professional support. Concerns about litigation typically emerge during this phase, with increasingly intense introspection eliciting painful self-questioning, such as "Why did I do this?" "Is there something wrong with me?" "Who can help me as I go through this?"
6. Finally, in stage six, the clinician's actions and thoughts lead to either dropping out ("Can I handle this work?"), surviving and coping ("How could I have prevented this?" "Why do I feel so bad?"), or thriving ("How can I improve safety?" "What can I learn from this?") Other characteristics of the thriving phase may include seeing the event as motivation to advocate for patient safety and framing the error event within the broader perspective of previously successful life behaviors and medical practice.