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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