The predicament of the second victim of patient safety incidents

The concept of the second victim of patient safety incidents was introduced by Albert Wu in his paper titled Medical error: the second victim. Whilst Wu acknowledged that ‘patients are the first and obvious victims of medical mistakes‘, he nevertheless argued that the doctors involved in the incidents are ‘wounded by the same errors’. Wu discussed the emotional turmoil they undergo, and particular’y highlighted how little support they receive from their institutions which tend to view every error as an anomaly ‘for which the solution is to ferret out and blame an individual’. Beyond the lack of institutional support, Wu pointed out that these second victims also receive only ‘grudging or qualified‘ support from their colleagues whose medical tradition mistakenly encourages them to ‘deny the existence of error‘ and to consider themselves ‘infallible‘.

Don’t be. Ferdinand Feys on Flickr.

The psychological burden is by far the most immediate impact of patient safety incidents on affected doctors. Tracing the onset of this emotional repercussion to ‘the sickening realisation of making a bad mistake‘, Wu portrayed its escalation as the doctor goes through the distress of feeling ‘singled out and exposed‘; the questioning of his or her competence; the dread of ‘the prospect of potential punishment and of the patient’s anger‘; and the agonising over ‘what to do, whether to tell anyone, what to say’. Wu illustrated the dilemma the doctor faces in this situation where ‘confession is discouraged’ and there are no ‘appropriate forums for discussion’, and where ‘there are no institutional mechanisms to aid the grieving process‘. Compounding the second victim’s predicament, Wu pointed out, is the poorly developed ‘mechanisms for healing‘ after error which afflict all doctors. This is why Wu remarked that second victims may end up displaying ‘dysfunctional ways‘ of protecting themselves such as with defensiveness, callousness, and anger, or by projecting blame to other healthcare team members, or even to the patient. As a tragic outcome, Wu observed that the ‘deeply wounded‘ doctor may eventually burnout and ‘seek solace in alcohol or drugs‘.

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The emotional burden of the second victim is also the focus of a paper titled Supporting health care workers after medical error: considerations for health care leaders. Written by Andrew White and colleagues, the paper explored the ‘intense negative emotions‘ doctors experience following patient safety incidents, and noting that these may persist for years. The emotions the authors reviewed included fear, guilt, anger, embarrassment, humiliation, disappointment, self-doubt, self-blame, anxiety about future errors, and depression. Apart from highlighting the destructive consequences of these emotions, such as substance abuse, post-traumatic stress disorder, burnout, and suicide, the authors also discussed factors that exacerbate these emotional problems, for example loss of confidence, reduced job satisfaction, impaired job performance, and reputational harm. When they do carry on working, White and colleagues pointed out that second victims may apply dysfunctional ways of managing ‘the vulnerability and discomfort of making mistakes’, such as by denial, distancing, discounting, and disproportional caution with ‘overuse of tests and procedures’. The authors were particularly concerned about the dearth of forums for doctors to have a ‘healthy, nonjudgmental, and open discussion of their mistakes’, facilities that help to mitigate the consequences of becoming a second victim.

Urban expression of depression at Tivoli Park. William Murphy on Flickr.

Matthew Grissinger also explored the psychological impacts of patient safety incidents on affected healthcare workers in his paper titled Too many abandon the “second victims” of medical errors. Grissinger argues that ‘patient tragedies caused by medical errors can shake the involved practitioners to their very core‘, adding that ‘in many cases, their lives fall apart‘. In addition to many of the consequences listed above, he also added sadness, panic, horror, apprehension, disbelief, shock, stress reaction, remorse, intrusive memories, excitability, nervousness, anguish, frustration, and hypervigilance to the retinue of catastrophes that befall the second victim. Maintaining that ‘second victims suffer a medical emergency‘, he said ‘the impact of the errors is felt in their private and social lives, and in their interactions with professional colleagues. Beyond the emotional effects, Grissinger also pointed out other professional and economic consequences of becoming a second victim, and these included fines, loss of job, loss of income, and loss of professional license. Second victims, he added, may also be anxious about returning to work because of their fear of being viewed as incompetent or careless by colleagues.

Her face. Beth Punches on Flickr.

Negligence claims are a major source of additional distress for the second victim, and this is a theme that Marlynn Wei explored in her paper titled Doctors, apologies, and the law: an analysis and critique of apology laws. Observing that ‘physicians feel angry and insulted by lawsuits – perceiving them as a challenge to their authority and their integrity‘, Wei illustrated the wider impact of malpractice suits which ‘strike a heavy blow to physicians’ and threaten the careers and reputation they ‘have invested in and prepared for meticulously for years’. Lawsuits, she added, often provoke strong emotional and physical reactions which often persist ‘even if the physician won the case’. She therefore argued that it is the allegation more than the outcome of the case that triggers the emotional responses, emphasising that ‘being cleared of the charge does little to lift those burdens‘. Wei also highlighted the long-term consequences of malpractice suits on the physician’s clinical practice such as by ‘ordering unnecessary tests, changing record keeping, avoiding high-risk procedures or certain patients, and even choosing early retirement‘.

Vik Muniz. Rocor on Flickr.

In the next post, we will look at how to safeguard the second victim of patient safety incidents.

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