Morally managing medical mistakes

Suicide Risk, Changing Jobs, or Leaving the Nursing Profession in the Aftermath of a Patient Safety Incident

BACKGROUND

Nursing retention is a concern for healthcare systems, hospital administrators, and nurses who have spent considerable time and money to achieve educational goals. Nearly, 33% of nurses will drop out in the 2 years practice. Those who stay in practice face an increased risk of suicide when compared the general population.

AIMS

To examine the relationship between nurse sociodemographic data and unique study variables with potential morally injurious outcomes (i.e., dropping out variables: changing jobs, intention to leave the profession, or suicidal thinking).

METHODS

A descriptive, correlational study design was used to characterize the relationship between the sociodemographic data of 216 registered nurses (RNs) and patient safety and the suicidal behavioral questionnaire.

RESULTS

RNs involved in a patient safety incident (PSI) considered changing jobs when the degree of harm was death (p < .001) or was unknown (p < .05) when compared with no harm. RNs were more likely to consider leaving the profession when the degree of harm to the patient was permanent (p < .01) or the patient died (p < .05) when compared with having no harm. RNs future suicidal thinking (i.e., their self-reported likelihood of future suicidal behavior) was statistically significant when degree of harm to the patient was death (p < .05) as a result of a PSI (95% CI [1.11, 8.71]) when compared with no harm. The RNs who had suicidal thoughts over the past year compared with those without and the RNs with future suicidal thinking compared with those without, may respond differently in the aftermath of a PSI.

LINKING EVIDENCE TO ACTION

This study served as a pioneering effort to the current understanding between nurse characteristics and patient harm and "dropping out" outcomes in RNs involved in PSIs. RNs involved with PSIs that led to more harm were more likely to change jobs, consider leaving the profession, or contemplate future suicide. These findings have important implications for nurses, administrative managers in healthcare organizations, and researchers.

Following-up midwives after adverse incidents: How front-line management practices help second victims

OBJECTIVE

To describe how front-line managers of maternity wards provide support to midwives as second victims in the aftermath of an adverse incident.

DESIGN

A qualitative study using critical incident technique and a content analytic approach of semi-structured in-depth interviews.

SETTING

Maternity wards in 10 Norwegian hospitals with more than 200 registered births annually were included in the study.

PARTICIPANTS

A purposeful sample of 33 midwives with more than two years' working experience described 57 adverse incidents.

FINDINGS

Maternity ward managers utilised four types of practices to support midwives after critical incidents: management, transformational leadership, distributed leadership and laissez-faire leadership.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The study shows that proactive managers who planned for how to handle critical incidents provided midwives with needed individual support and learning. Proactive transformational leadership and delegating roles for individual support should be promoted when assisting second victims after critical incidents. Managers can limit the potential harm to second victims by preparing for the eventuality of a crisis and institute follow-up practices.

Complications: acknowledging, managing, and coping with human error

Errors are inherent in medicine due to the imperfectness of human nature. Health care providers may have a difficult time accepting their fallibility, acknowledging mistakes, and disclosing errors. Fear of litigation, shame, blame, and concern about reputation are just some of the barriers preventing physicians from being more candid with their patients, despite the supporting body of evidence that patients cite poor communication and lack of transparency as primary drivers to file a lawsuit in the wake of a medical complication. Proper error disclosure includes a timely explanation of what happened, who was involved, why the error occurred, and how it will be prevented in the future. Medical mistakes afford the opportunity for individuals and institutions to be candid about their weaknesses while improving patient care processes. When a physician takes the Hippocratic Oath they take on a tremendous sense of responsibility for the care of their patients, and often bear the burden of their mistakes in isolation. Physicians may struggle with guilt, shame, and a crisis of confidence, which may thwart efforts to identify areas for improvement that can lead to meaningful change. Coping strategies for providers include discussing the event with others, seeking professional counseling, and implementing quality improvement projects. Physicians and health care organizations need to find adaptive ways to deal with complications that will benefit patients, providers, and their institutions.

Always Having to Say You’re Sorry: an ethical response to making mistakes in professional practice

Efforts to decrease errors in health care are directed at prevention rather than at managing a situation when a mistake has occurred. Consequently, nurses and other health care providers may not know how to respond properly and may lack sufficient support to make a healthy recovery from the mental anguish and emotional suffering that often accompany making mistakes. This article explores the conceptualization of mistakes and the ethical response to making a mistake. There are three parts to an ethical response to error: disclosure, apology and amends. Honesty and humility are discussed as important virtues that facilitate coping and personal growth for the health care provider who is involved in mistakes. In conclusion, a healthy view of nursing practice and mistake making is one that prevents error but, when prevention is not possible, accepts fallibility as part of the human condition and achieves the best possible outcome for all.

How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study

OBJECTIVE

Surgical trainees are often subject to the negative consequences of medical error, and it is therefore important to determine how trainees cope with error and to find ways of supporting trainees when catastrophic events occur. This article examines how trainees interpret catastrophic surgical outcomes and ways to provide support for trainees who have experienced catastrophic events.

DESIGN

Totally 23 semistructured interviews were conducted with surgical trainees. Interviews were conducted in English and subjected to modified thematic analysis.

SETTING

A tertiary care hospital in Toronto, Canada.

PARTICIPANTS

Interviews were completed with 23 surgery residents. Potential participants were recruited through communications via the Department of Surgery and volunteered to take part in the study.

RESULTS

Totally 5 themes emerged: (1) catastrophic errors usually represent system deficiencies; (2) catastrophic events provide lessons for future practice; (3) many trainees did not feel comfortable speaking with the surgical staff; (4) counseling services should be offered to help a subset of trainees; and (5) the culture of surgery may act as a barrier to trainees seeking help.

CONCLUSIONS

This study demonstrates the importance of providing support for the emotional needs of surgical trainees who have experienced catastrophic surgical errors and the continued need for mentoring by staff surgeons.

Medical error, disclosure and patient safety: a global view of quality care

Medical errors are a prominent issue in health care. Numerous studies point at the high prevalence of adverse events, many of which are preventable. Although there is a range of severity in errors, they all cause harm, to the patient, to the system, or both. While errors have many causes, including human interactions and system inadequacies, the focus on individuals rather than the system has led to an unsuitable culture for improving patient safety. Important areas of focus are diagnostic procedures and clinical laboratories because their results play a major role in guiding clinical decisions in patient management. Proper disclosure of medical errors and adverse events is also a key area for improvement. Globally, system improvements are beginning to take place, however, in Canada, policies on disclosure, error reporting and protection for physicians remain non-uniform. Achieving a national standard with mandatory reporting, in addition to a non-punitive system is recommended to move forward.

Health care professionals as second victims after adverse events: a systematic review

Adverse events within health care settings can lead to two victims. The first victim is the patient and family and the second victim is the involved health care professional. The latter is the focus of this review. The objectives are to determine definitions of this concept, research the prevalence and the impact of the adverse event on the second victim, and the used coping strategies. Therefore a literature research was performed by using a three-step search procedure. A total of 32 research articles and 9 nonresearch articles were identified. The second victim phenomenon was first described by Wu in 2000. In 2009, Scott et al. introduced a detailed definition of second victims. The prevalence of second victims after an adverse event varied from 10.4% up to 43.3%. Common reactions can be emotional, cognitive, and behavioral. The coping strategies used by second victims have an impact on their patients, colleagues, and themselves. After the adverse event, defensive as well as constructive changes have been reported in practice. The second victim phenomenon has a significant impact on clinicians, colleagues, and subsequent patients. Because of this broad impact it is important to offer support for second victims. When an adverse event occurs, it is critical that support networks are in place to protect both the patient and involved health care providers.

The role of talking (and keeping silent) in physician coping with medical error: a qualitative study

OBJECTIVE

The aim was to examine the role of talking (or remaining silent) in the physician's experience of coping with medical error.

METHODS

Sixty-one physicians participated in in-depth interviews about their experience of coping with a serious medical error. We analyzed verbatim transcripts to develop a taxonomic analysis of talking domains to capture the physician experience of talking and coping with error.

RESULTS

Talking (or not talking) about a medical error was an important aspect of the physicians' experience. After an error, honest conversations with patients and families, the medical team, colleagues, mentors, and others were critical early steps toward healing. Talking with others was important for processing and finding meaning. Many physicians used their stories to teach and help others. Some types of conversation were unhelpful, such as those that were cruel, insensitive, self-serving, and dishonest. Talking with well-intentioned colleagues and family members was often unhelpful if they minimized the error.

CONCLUSION

Physicians' opportunities to talk about their experience in a meaningful way is associated with their ability to recover after a serious medical error.

PRACTICE IMPLICATIONS

This work may inform institutional policies, practices, and training to help physicians effectively prepare for and cope with medical error.

Perceptions of emergency medicine residents and fellows regarding competence, adverse events and reporting to supervisors: a national survey

OBJECTIVE

We sought to characterize the perceptions of emergency medicine (EM) residents and fellows of their clinical and procedural competence, as well as their attitudes, practices and perceived barriers to reporting these perceptions to their supervisors.

METHODS

A Web-based survey was distributed to residents and fellows, via their residency directors, in all Canadian EM residency programs outside of Quebec.

RESULTS

Of 220 residents and fellows contacted in 9 of 10 EM programs of the Royal College of Physicians and Surgeons of Canada and 12 of 13 EM programs of The College of Family Physicians of Canada, 82 (37.3%) completed all or part of the survey. Response rates varied slightly by question; 25 of 82 re-spondents (30.5% [95% confidence interval (CI) 19.9%-41.1%]) agreed with the statement, "I sometimes feel unsafe or un-qualified with undertaking unsupervised responsibilities or procedures, but I do not report this to my senior physician" and 32 of 81 (39.5% [95% CI 28.2%-50.8%]) had felt this within the past 6 months. Moreover, 34 of 82 (41.5% [95% CI 30.2%-52.7%]) reported their lack of competence to a supervisor half the time or less. Trainees reported worry about loss of trust, autonomy or respect (38/80, 47.5% [95% CI 35.9%-59.1%]) or reputation (32/80, 40.0% [95% CI 28.6%-51.4%]). Nights on-call (30/79, 38% [95% CI 26.6%-49.3%]), admission decisions (13/79, 16.5% [7.6%-25.3%]) and central line insertion (13/79, 16.5% [95% CI 7.6%-25.3%]) were reported to be frequently undertaken despite not feeling competent. Suggestions to improve reporting included encouragement to report without penalty (41/82, 50.0% [95% CI 38.6%-61.4%]) and a less judgmental environment (32/82, 39.0% [95% CI 27.9%-50.2%]).

CONCLUSION

Emergency medicine trainees report that they frequently do not feel competent when undertaking responsibilities without supervision. Barriers to reporting these feelings or reporting adverse events appear to relate to social pressures and authority gradients. Modifications to the training culture are encouraged to improve patient safety.

The subjective incremental cost of informed consent and documentation in hospital care: a multicentre questionnaire survey in Japan

OBJECTIVE

To reveal the amount of time and financial cost required to obtain informed consent and to preserve documentation.

METHODS

The questionnaire was delivered to all staff in six acute care public hospitals in Japan. We examined health care staff perceptions of the time they spent obtaining informed consent and documenting information. All data were collected in 2006 and estimates in the past week in 2006 were compared to estimates of time spent in a week in 1999. We also calculated the economic costs of incremental amounts of time spent in these procedures.

RESULTS

In 2006, health care staff took about 3.89 hours [95% Confidence Interval (CI) 3.71-4.07] per week to obtain informed consent and 6.64 hours (95% CI 6.40-6.88) per week to write documentation on average. Between 1999 and 2006, the average amount of time for conducting informed consent was increased to 0.67 (P < 0.001) hours per person-week, and the average amount of time for documentation was increased to 0.70 (P < 0.001) hours per person-week. The annual economic cost of activities for informed consent and documentation in a 100-bed hospital increased from 117 755 to 449 402 US dollars.

CONCLUSIONS

We found a considerable increase in time spent on informed consent and documentation, and associated cost over a 7-year time period. Although greater attention to the informed consent process should be paid to ensure the notions of patient autonomy and self-determination, the increased resources devoted to these practices must be considered in light of current cost containment policies.

Toward a theory of self-reconciliation following mistakes in nursing practice

PURPOSE

To explore nurses' responses to making mistakes in hospital-based practice in the US.

METHODS

A grounded theory approach was used to explore the process that occurs after nurses perceive that they have made mistakes in practice. Theoretical sampling was used and data were collected until saturation occurred. Ten participants, who were registered nurses, described 17 personal mistakes. The mistakes they described occurred in hospitals. All participants were practicing nursing either in hospitals or in other work settings.

FINDINGS

A process of "Self-Reconciliation After Making Mistakes in Hospital Practice" was identified, with four distinct categories: reality hitting, weighing in, acting, and reconciling. The core category was reconciliation of the self, personally and professionally.

CONCLUSIONS

This research was a first step toward the development of a theory of mistake making in nursing practice. This response to making mistakes is consistent with previous research and is related to cognitive dissonance theory. The responses to mistakes varied from less healthy responses of blaming and silence to healthier responses that included disclosure, apologizing, and making amends. Further research to develop the theory and to determine helpful interventions is suggested.

The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada

BACKGROUND

Being involved in medical errors can compound the job-related stress many physicians experience. The impact of errors on physicians was examined.

METHODS

A survey completed by 3,171 of the 4,990 eligible physicians in internal medicine, pediatrics, family medicine, and surgery (64% response rate) examined how errors affected five work and life domains.

RESULTS

Physicians reported increased anxiety about future errors (61%), loss of confidence (44%), sleeping difficulties (42%), reduced job satisfaction (42%), and harm to their reputation (13%) following errors. Physicians' job-related stress increased when they had been involved with a serious error. However, one third of physicians only involved with near misses also reported increased stress. Physicians were more likely to be distressed after serious errors when they were dissatisfied with error disclosure to patients (odds ratio [OR] = 3.86, confidence interval [CI] = 1.66, 9.00), perceived a greater risk of being sued (OR = .28, CI = 1.50, 3.48), spent greater than 75% time in clinical practice (OR = 2.20, CI = 1.60, 3.01), or were female (OR = 1.91, CI = 1.21, 3.02). Only 10% agreed that health care organizations adequately supported them in coping with error-related stress.

DISCUSSION

Many physicians experience significant emotional distress and job-related stress following serious errors and near misses. Organizational resources to support physicians after errors should be improved.

Preventable harm occurring to critically ill children

OBJECTIVE

To develop a trigger tool for identifying adverse events occurring in critically ill pediatric patients; to identify and characterize adverse events and preventable adverse events experienced by critically ill pediatric patients; and to characterize the patients who experience preventable adverse events.

DESIGN

Retrospective chart review using a trigger tool.

SETTING

Pediatric intensive care unit of a tertiary, university-affiliated pediatric hospital.

PATIENTS

A systematic sample of 259 pediatric intensive care unit patients from a 1-yr period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We measured frequency of occurrence (0.19 preventable adverse events per patient-day), severity of harm (78% minor, 19% moderate, 3% serious, no deaths), and type of event (sedation, 22%; skin, 16%; medical device complication, 14%; pulmonary, 13%; and cardiovascular, 11%). Patients who experienced preventable adverse events were younger, had longer lengths of stay, and had higher illness burdens. Preventable adverse events occurred more frequently among surgical patients than medical patients.

CONCLUSIONS

Preventable adverse events occurred fairly frequently in the pediatric intensive care unit, but serious harm was rare. Conditions that increased the likelihood of a preventable adverse event were a) need for sedation or pain control; b) relative immobility; and c) need for vascular devices, feeding tubes, or ventilators. Adverse event prevention strategies that focus on improving patient monitoring under increased-risk conditions and improving early detection and treatment of potential harm will likely be more effective than strategies aimed at general error prevention.

Disclosure of medical errors: what factors influence how patients respond?

BACKGROUND

Disclosure of medical errors is encouraged, but research on how patients respond to specific practices is limited.

OBJECTIVE

This study sought to determine whether full disclosure, an existing positive physician-patient relationship, an offer to waive associated costs, and the severity of the clinical outcome influenced patients' responses to medical errors.

PARTICIPANTS

Four hundred and seven health plan members participated in a randomized experiment in which they viewed video depictions of medical error and disclosure.

DESIGN

Subjects were randomly assigned to experimental condition. Conditions varied in type of medication error, level of disclosure, reference to a prior positive physician-patient relationship, an offer to waive costs, and clinical outcome.

MEASURES

Self-reported likelihood of changing physicians and of seeking legal advice; satisfaction, trust, and emotional response.

RESULTS

Nondisclosure increased the likelihood of changing physicians, and reduced satisfaction and trust in both error conditions. Nondisclosure increased the likelihood of seeking legal advice and was associated with a more negative emotional response in the missed allergy error condition, but did not have a statistically significant impact on seeking legal advice or emotional response in the monitoring error condition. Neither the existence of a positive relationship nor an offer to waive costs had a statistically significant impact.

CONCLUSIONS

This study provides evidence that full disclosure is likely to have a positive effect or no effect on how patients respond to medical errors. The clinical outcome also influences patients' responses. The impact of an existing positive physician-patient relationship, or of waiving costs associated with the error remains uncertain.

Emergency physicians and disclosure of medical errors

Error in medicine is a subject of continuing interest among physicians, patients, policymakers, and the general public. This article examines the issue of disclosure of medical errors in the context of emergency medicine. It reviews the concept of medical error; proposes the professional duty of truthfulness as a justification for error disclosure; examines barriers to error disclosure posed by health care systems, patients, physicians, and the law; suggests system changes to address the issue of medical error; offers practical guidelines to promote the practice of error disclosure; and discusses the issue of disclosure of errors made by another physician.

Characteristics of medication errors made by students during the administration phase: a descriptive study

Faculty concentrate on teaching nursing students about safe medication administration practices and on challenging them to develop skills for calculating drug dose and intravenous flow rate problems. In spite of these efforts, students make medication errors and little is known about the attributes of these errors. Therefore, this descriptive, retrospective, secondary analysis study examined the characteristics of medication errors made by nursing students during the administration phase of the medication use process as reported to the MEDMARX, a database operated by the United States Pharmacopeia through the Patient Safety Program. Fewer than 3% of 1,305 student-made medication errors occurring in the administration process resulted in patient harm. Most were omission errors, followed by errors of giving the wrong dose (amount) of a drug. The most prevalent cause of the errors was students' performance deficits, whereas inexperience and distractions were leading contributing factors. The antimicrobial therapeutic class of drugs and the 10 subcategories within this class were the most commonly reported medications involved. Insulin was the highest-frequency single medication reported. Overall, this study shows that students' administration errors may be more frequent than suspected. Faculty might consider curriculum revisions that incorporate medication use safety throughout each course in nursing major courses.

Medical errors: overcoming the challenges

The issue of medical errors has received substantial attention in recent years. The Institute of Medicine (IOM) report released in 1999 has several implications for health care systems in all disciplines of medicine. Notwithstanding the plethora of available information on the subject, little, by way of substantive action, is done toward medical error reduction. A principal reason for this may be the stigma associated with medical errors. An educational program with a practical, informed, and longitudinal approach offers realistic solutions toward this end. Effective reporting systems need to be developed as a medium of learning from the errors and modifying behaviors appropriately. The presence of a strong leadership supported by organizational commitment is essential in driving these changes. A national, provincial or territorial quality care council dedicated solely for the purpose of enhancing patient safety and medical error reduction may be formed to oversee these efforts. The bioethical and emotional components associated with medical errors also deserve attention and focus.

Two models of mistake-making in professional practice: moving out of the closet

Nurses make mistakes in practice despite the culturally based expectation of perfection. Such a disparity between reality and expectation calls members of the profession to question the current attitudes toward mistakes in practice. Two explanatory models of the origin of mistakes are presented. The Perfectibility Model holds that any error or harm is caused by an individual practitioner's lack of knowledge or motivation. The Faulty Systems Model offers a broader explanation of human error. I conclude that a Faulty Systems Model is more comprehensive and more effective for managing mistakes. Integrating the Faulty Systems Model into practice and education can result in more ethically fitting responses to errors and ultimately better outcomes for nurses, institutions and patients.

Disclosing Adverse Events to Patients

BACKGROUND

The rationale for, and recommended approaches to, disclosing adverse events to patients are examined on the basis of the experience of the Veterans Health Administration (VHA). The VHA's National Ethics Committee endorses a general policy requiring the routine disclosure of adverse events to patients and offers practical recommendations for implementation.

PRACTICAL APPROACHES TO DISCLOSING ADVERSE EVENTS

Disclosure is required when the adverse event (1) has a perceptible effect on the patient that was not discussed in advance as a known risk; (2) necessitates a change in the patient's care; (3) potentially poses an important risk to the patient's future health, even if that risk is extremely small; (4) involves providing a treatment or procedure without the patient's consent. From an ethical perspective, disclosure is required and should not be limited to cases in which the injury is obvious or severe. Disclosure of near misses is also discretionary but is advisable at times. In general, disclosure by a clinician involved in the patient's care is appropriate.

CONCLUSION

Although a variety of psychological and cultural factors may make clinicians and organizations reluctant to disclose adverse events to patients, the arguments favoring routine disclosure are compelling. Organizations should develop clear policies supporting disclosure and should create supportive environments that enable clinicians to meet their ethical obligations to disclose adverse events to patients and families.

Safety in training and learning in the intensive care unit

Resident and subspecialty fellow trainees in the intensive care unit (ICU) present risks for patient safety because of their inexperience yet offer opportunities to promote safe patient care because of their around-the-clock presence and their involvement in frontline processes of care. Most trainees approach their ICU experiences without previous education in performance improvement or patient safety. This article reviews the barriers that are faced by residents in providing safe patient care and outlines the nature of a patient safety curriculum that could tap the opportunities that are presented by trainees to promote safer patient care.

Medical errors-what and when: what do patients want to know?

OBJECTIVES

1) To determine how and when emergency department (ED) patients and their families wish to learn of health care errors. 2) To assess the error threshold this population believes should trigger reporting to government agencies, state medical boards, and hospital patient safety committees. 3) To evaluate the role patients and families believe medical educators should play in this process.

METHODS

A 12-item survey was administered to a convenience sample of ED patients and families during evaluation in a tertiary care academic ED. Results were tabulated and data were reported as percentages. Statistical significance was analyzed using the chi-square test.

RESULTS

258 surveys were returned (80%). A majority of respondents wished to be informed immediately of any medical error (76%) and to have full disclosure of the error's extent (88%). An overwhelming majority of respondents endorse reporting of errors to government agencies (92%), state medical boards (97%), and hospital committees (99%). Most respondents believe medical educators should focus on teaching students to be honest and compassionate (38%) or on how to tell patients about mistakes (25%). The frequency of hospital admission or physician visits per year had no impact on any response pattern (ns with chi(2) test).

CONCLUSIONS

Regardless of health care utilization, a majority of respondents want full disclosure of medical error and wish to be informed of error immediately upon its detection. Respondents support reporting of errors to government agencies, the state medical board, and hospital committees focused on patient safety. Teaching physicians error disclosure techniques, honesty, and compassion were endorsed as a priority for educators who teach error management.

Coping with medical mistakes and errors in judgment

Attention has recently been focused on medical errors as a cause of morbidity and mortality in clinical practice. Although much has been written regarding the cognitive aspects of decision making and the importance of systems management as an approach to medical error reduction, little consideration has been given to the emotional impact of errors on the practitioner. Evidence exists that errors are common in clinical practice and that physicians often deal with them in dysfunctional ways. However, there is no general acknowledgment within the profession of the inevitability of medical errors or of the need for practitioners to be trained in their management. This article focuses on the affective aspects of physician errors and presents a strategy for coping with them.