Cases & Commentaries

How Do Providers Recover From Errors?

Spotlight Case
Commentary By Colin P. West, MD, PhD

Case Objectives

  • Describe the provider-specific
    prevalence of medical errors.
  • Appreciate the impact of medical errors
    on care providers.
  • Understand coping strategies, including
    error disclosure.
  • Review potential support structures for
    providers involved in errors.

Case & Commentary: Part 1

An 81-year-old man with chronic obstructive
pulmonary disease and end-stage congestive heart failure was
admitted to the hospital with complaints of increasing shortness of
breath. A chest radiograph revealed a moderate sized right-sided
pleural effusion. He was treated with diuresis and bronchodilators.
However, after 2 days and a net output of more than 2.7 liters, he
continued to be dyspneic, requiring more supplemental oxygen than
baseline. The primary team decided to perform a therapeutic
thoracentesis. The resident on the primary team had not performed
the requisite number of thoracenteses and therefore could not
perform this procedure without supervision. A resident from another
team who had performed the required number of thoracenteses offered
to perform the procedure, and the primary team's resident accepted
this offer. Consent was obtained from the patient and his wife. The
resident performed the thoracentesis but was unable to draw any
fluid, aspirating only a small amount of blood and air. The
resident then realized that the effusion was on the contralateral
side, not the left side she had just tapped. One hour after the
procedure, the patient developed hemoptysis, and a chest radiograph
revealed a pneumothorax on the left and a persistent unchanged
pleural effusion on the right.

This case unfortunately represents an
all-too-common occurrence in modern medical practice. The
proportion of hospitalized patients affected by medical errors has
been estimated to be 5% to 10%, although it has approached 50% in
some studies.(1) The
majority of reports on medical error rates have focused on
patient-specific rates. Less commonly addressed but also of
interest is the proportion of physicians who commit errors.
Essentially the entire literature on this subject concerns resident
physicians; data on fully trained practitioners are
scarce.(2)

Among residents, several studies have addressed
this question. In an early report, Mizrahi (3) found that 47% of internal medicine residents reported
making serious errors during their training. Subsequently, Wu and
colleagues (4)
found a similar proportion (45%). More recently, Jagsi and
colleagues (5)
surveyed residents across multiple specialties and found that 18%
reported an adverse event under their care in the previous week,
with one-third of these events classified as mistakes. In a sample
limited to internal medicine residents, another study (1)
found that 34% reported at least one major medical error during
their training. This figure represented an underestimate of the
true proportion, since it included residents completing less than
the full 3 years of categorical residency training at the time of
the report.

Each of these studies relied on self-report; very
little is known about actual error rates, although most care
providers would probably recognize that it is essentially
impossible to complete training without making at least one major
error. This suggests that self-reported error rates may actually
represent a lower bound on the true incidence of medical errors. It
seems clear that such errors are common, but better tracking is
needed before these rates can be more accurately described.

Committing errors can have a significant impact
on clinicians, who have been termed the "second victims" of medical
errors.(6) In
one study of internal medicine residents, committing an error led
to a 3-fold increase in depression, accompanied by a clinically
meaningful increase in burnout and decrease in overall quality of
life.(1)
This is particularly notable given the high baseline rates of
physician distress in modern medicine. Waterman and colleagues have
also reported high rates of anxiety, loss of confidence, sleeping
difficulties, and reduced job satisfaction following
errors.(7)
Thus, feelings of distress, guilt, shame, and depression are common
(1,7,8)
and may be long-lasting. Some physicians may even feel "permanently
wounded" as a result.(9)
These feelings appear to occur regardless of stage of
training.(10)

Predicting the impact of an error is difficult,
although 2 factors related to the error itself have been proposed.
One is the patient outcome resulting from the error, and the other
is the degree of personal responsibility felt for the error. As
might be expected, errors for which the provider feels directly and
fully responsible, and those that result in patient death or severe
morbidity, have the greatest impact.(10)

Given the significant impact that errors can have
on providers, how can these errors be processed to minimize the
damage they can cause? Certainly, prevention is one key: an error
avoided is a recovery process that never needs to begin. However,
once an error has occurred, the literature suggests several
important steps.(11)

First, it is important to avoid counterproductive
responses to errors. For example, maladaptive behaviors such as
emotional repression, patient avoidance, and defensive medical
practice are unlikely to benefit patients or providers.(10,12,13)

Second, among more positive steps toward
successfully processing errors, accepting responsibility is
crucial, as is the logical follow-up to this, pursuing additional
training to better understand and correct mistakes.(14) It is particularly important for physicians to
understand that the need for support after an error is normal, not
a sign of weakness. A common but by no means universal (15)
coping mechanism is discussion with colleagues and family
members.(10,16)
Sources of support may come informally from within a clinician's
professional and social network but may also include error
disclosure to patients and family members.

Historically, disclosure of errors to patients
has been controversial, although the importance of disclosure to
the physician-patient relationship is clear. There are few
quantitative data on the impact of disclosure to patients on
physician distress after errors, but in one study, physicians
dissatisfied with error disclosure to patients had markedly higher
rates of distress.(7)
Additional qualitative data suggest that error disclosure (and
apology when appropriate) to patients represents an important and
positive step toward resolution for both patients and care
providers after a medical error.(8,12,17,18) This remains an area requiring further
research.

Case & Commentary: Part 2

The resident provided full disclosure to the
wife immediately following the procedure. The patient continued to
deteriorate and died approximately 4 hours after the thoracentesis.
The resident was devastated by the error. One week after the
patient passed away, the wife called the hospital where the event
occurred and asked for the resident. The wife wanted to thank her
for her honesty and to check to see if the resident was doing okay
after the event.

As discussed, this resident's emotional response
to the error is typical, especially given the resident's direct
causative role and the patient's poor outcome. While some legal
experts may highlight the perceived risk of full error disclosure
(as described in this case) (19),
such disclosure is clearly the appropriate action once an error has
taken place. Interestingly, while it is not appropriate to burden
patients and their families with care providers' own distress about
errors, it is quite common for families to reach out to trusted
physicians in these situations when they see integrity, honesty,
and genuine hurt. Because this cannot be relied upon as the sole
source of support, however, a key question is what other means of
support are available for providers after errors occur?

Given what is known about the impact of medical
errors on physicians, it is perhaps surprising that there are
relatively few formal support programs available for providers
after errors occur.(6) As
described previously, providers often rely on informal support
structures such as family, friends, and colleagues. More formalized
structures are poorly defined in the literature and have not been
subjected to rigorous scientific scrutiny.

Suggested forums for processing errors include
case reviews, which may occur informally in small groups or
formally in conferences such as the traditional morbidity and
mortality (M&M) conferences at many institutions.(10,14,20,21) These conferences historically have been
extensions of the culture of medicine in which errors are regarded
as lapses resulting from unacceptable personal fallibility and
therefore may place providers at risk for public humiliation and
shame.(11,14,22) However, if discussions are framed differently,
such conferences can represent a powerful opportunity for
professional role modeling of error acknowledgment and open
discussion.(10,21)
On a more individual level, emotional support may be provided by
institutional "confessor" figures with whom physicians can discuss
errors confidentially.(14) It
is important, however, that such figures not be part of the
clinician's performance evaluation team.

Clearly, additional steps are necessary to
standardize support for physicians after medical errors.
Specifically, institutional efforts to put medical error teaching
programs in place throughout medical training would be helpful.
These programs should help providers understand that errors are a
part of any human endeavor, and while we strive for perfection in
medicine, perfection is simply not possible. Programs should then
also help providers understand the coping strategies that others
find helpful, as well as caution against maladaptive strategies.
Finally, these programs should promote open discussion of errors in
a manner designed to foster personal and institutional growth
rather than humiliate and assign blame. One potential role model
for such efforts is the Brigham and Women's Hospital Peer Support
Team.(23) In
this program, a multidisciplinary team provides one-on-one peer
support for any physician requesting it, and group sessions are
used in situations involving major events. By publicly supporting
such measures, teaching faculty, medical school and residency
leadership, and institutional administration may better address the
impact of medical errors on caregivers at all stages of medical
training and practice.

Take-Home Points

  • Medical errors are an unavoidable part
    of medical practice resulting in significant distress for care
    providers.
  • Coping strategies are necessary and
    range from personal approaches to formal organized forums for
    discussion of errors.
  • Institutional efforts should focus on
    implementing curricula in medical errors at all levels of medical
    training.
  • A culture shift will be necessary to
    create a productive process for the provider sharing the medical
    error.

Colin P. West, MD, PhD
Assistant Professor of Medicine
Mayo Clinic College of Medicine

Faculty Disclosure: Dr. West has
declared that neither he, nor any immediate member of his family,
has a financial arrangement or other relationship with the
manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, his commentary
does not include information regarding investigational or off-label
use of pharmaceutical products or medical devices.

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