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Medical error: the second victim
The doctor who makes the mistake needs help too
When I was an intern, a resident failed to identify the
electrocardiographic signs of the pericardial tamponade
that would rush the patient to the operating room late that
night. The news spread rapidly, the case tried repeatedly
before an incredulous jury of peers, who returned a sum-
mary judgment of incompetence. I was dismayed by the
lack of sympathy and wondered secretly if I could have
made the same mistake—and, like the hapless resident,
become the second victim of the error.
Strangely, there is no place for mistakes in modern
medicine. Society has entrusted physicians with the bur-
den of understanding and dealing with illness. Although it
is often said, “doctors are only human,” technological
wonders, the apparent precision of laboratory tests, and
innovations that present tangible images of illness have in
fact created an expectation of perfection. Patients, who
have an understandable need to consider their doctors
infallible, have colluded with doctors to deny the existence
of error. Hospitals react to every error as an anomaly, for
which the solution is to ferret out and blame an indi-
vidual, with a promise that “it will never happen again.”
Paradoxically, this approach has diverted attention from
the kind of systematic improvements that could decrease
errors. Many errors are built into existing routines and
devices, setting up the unwitting physician and patient for
disaster. And, although patients are the first and obvious
victims of medical mistakes, doctors are wounded by the
same errors: they are the second victims.
Virtually every practitioner knows the sickening real-
ization of making a bad mistake. You feel singled out and
exposed—seized by the instinct to see if anyone has no-
ticed. You agonize about what to do, whether to tell any-
one, what to say. Later, the event replays itself over and
over in your mind. You question your competence but
fear being discovered. You know you should confess, but
dread the prospect of potential punishment and of the
patient’s anger. You may become overly attentive to the
patient or family, lamenting the failure to do so earlier
and, if you haven’t told them, wondering if they know.
1-3
Sadly, the kind of unconditional sympathy and sup-
..................
Op-Ed
Albert W Wu
School of Hygiene and
Public Health
and School of Medicine
Johns Hopkins
University
Baltimore, MD 21205
Correspondence to:
Dr Wu
awu@jhsph.edu
Competing interests:
None declared
This editorial was
previously published in
BMJ 2000;320:726-727
..............................................................................................................................................................................
358 wjm Volume 172 June 2000
port that are really needed are rarely forthcoming. While
there is a norm of not criticizing,
4
reassurance from col-
leagues is often grudging or qualified. One reason may be
that learning of the failings of others allows physicians to
divest their own past errors among the group, making
them feel less exposed.
5
It has been suggested that the only
way to face the guilt after a serious error is through con-
fession, restitution, and absolution.
6
But confession is dis-
couraged, passively by the lack of appropriate forums for
discussion, and sometimes actively by risk managers and
hospital lawyers. Further, there are no institutional mecha-
nisms to aid the grieving process.
Even when mistakes are discussed at morbidity and
mortality conferences, it is to examine the medical facts
rather than the feelings of the patient or physician. In the
absence of mechanisms for healing, physicians find dys-
functional ways to protect themselves. They often respond
to their own mistakes with anger and projection of blame
and may act defensively or callously and blame or scold
the patient or other members of the health care team.
Distress escalates in the face of a malpractice suit. In the
long run, some physicians are deeply wounded, lose their
nerve, burn out, or seek solace in alcohol or drugs.
6
My observation is that this number includes some of
our most reflective and sensitive colleagues, perhaps most
susceptible to injury from their own mistakes. What
should we do when a colleague makes a mistake? How
would we like others to react to our mistakes? How can we
make it feel safe to talk about mistakes? In the case of an
individual colleague, it is important to encourage a de-
scription of what happened and to begin by accepting this
assessment and not minimizing the importance of the
mistake. Disclosing one’s own experience of mistakes can
reduce the colleague’s sense of isolation. It is helpful to ask
about and acknowledge the emotional impact of the mis-
take and ask how the colleague is coping. If the patient or
family is not aware of the mistake, the importance of
disclosure should be discussed.
The physician has an ethical responsibility to tell the
patient about an error, especially if the error has caused
harm.
7
We should acknowledge the pain of implementing
this imperative. We can, however, convey the great relief it
can be to admit a mistake, and that, confronted by an
empathic and apologetic physician, patients and families
can be astonishingly forgiving. Only then is it appropriate
to approach the mistake with a problem-solving focus and
to explore what could have been done differently and what
changes can be made at the individual and institutional
level to prevent recurrence.
In the case of the misread electrocardiogram, the edu-
cational and emotional experience for the resident—and
the team—would have been transformed if a respected
senior clinician had led an open discussion of the incident
and acknowledged the inevitability of mistakes. Nurses,
pharmacists, and other members of the health care team
are also susceptible to error and vulnerable to its fallout.
Given the hospital hierarchy, they have less latitude to deal
with their mistakes: they often bear silent witness to mis-
takes and agonize over conflicting loyalties to patient, in-
stitution, and team. They, too, are victims.
I’ll conclude with an assignment for the practicing doc-
tor: think back to your last mistake that harmed a patient.
Talk to a colleague about it. Notice your colleague’s reac-
tions and your own. What helps? What makes it harder?
Physicians will always make mistakes. The decisive factor
will be how we handle them. Patient safety and physician
welfare will be well served if we can be more honest about
our mistakes to our patients, our colleagues, and ourselves.
....................................................................................................
References
1 Wu AW, Folkman S, McPhee SJ, et al. Do house officers learn from
their mistakes? JAMA 1991;265:2089-2094.
2 Christensen JF, Levinson W, Dunn PM. The heart of darkness: the
impact of perceived mistakes on physicians. J Gen Intern Med
1992;7:424-431.
3 Newman MC. The emotional impact of mistakes on family physicians.
Arch Fam Med 1996;5:71-75.
4 Rosenthal MM. The Incompetent Doctor. Behind Closed Doors.
Buckingham, England: Open University Press, 1995.
5 Terry JS, Fricchione GL. Facing limitation and failure. The Pharos
1985;Fall:13-18.
6 Hilfiker D. Healing the Wounds. A Physician Looks at His Work. New
York: Penguin; 1985.
7 Wu AW, Cavanaugh TA, McPhee SJ, et al. To tell the truth: ethical
and practical issues in disclosing medical mistakes to patients. J Gen
Intern Med 1997;12:770-775.
capsule
Festive weight gain Urban myth has it that the average American gains 5 pounds between Thanksgiving and New Year’s. The real
figure is less than a quarter of that, but it’s still enough to cause a substantial spare tire when multiplied over a lifetime, write
researchers from the US National Institutes of Health (NEnglJMed2000;342:861-867). Volunteers in a study of holiday excess
overestimated their weight gain by about 400%—but this did not inspire them to lose any of it over the following summer.
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Op-Ed
Volume 172 June 2000 wjm 359
... Following a medical error, most medical providers experience a broad range of feelings including guilt, remorse, anger and inadequacy [1,2]. The suffering of medical providers in the face of a serious medical error has become known as the second victim phenomenon, which may result in a period of profound professional and personal anguish, described by Wu in 2001 [3]. "Second victims are health care providers who are involved in an unanticipated adverse patient event, in a medical error and/or a patient related injury and become victimized in the sense that the provider is traumatized by the event. ...
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Background Physicians’ self-perceived medical errors lead to substantial emotional distress, which has been termed the “second victim phenomenon.” Medical errors during residency are associated with increased burnout and depression. It is important to know how residents cope with self-perceived medical errors and how they gain personal and emotional support in order to develop effective interventions. Objective To assess the impact of self-perceived medical errors on residents’ well-being, the range of coping strategies during training, and the extent of personal and institutional support. Methods An online cross-sectional survey was administered via email in October 2018 to 286 residents across all specialties in a 548-bed single urban academic medical center. The survey covered three domains focusing on residents’ most serious self-perceived medical error: (1) emotional response, (2) coping strategies using the BRIEF COPE Inventory, and (3) personal and institutional support. Results 109/286 residents from various specialties responded. Internal Medicine, Pediatrics and Emergency Medicine constituting 80 % of respondents. Self-perceived medical errors during residency were widespread (95 %). One in five medical errors was classified as moderate to severe. Most residents acknowledged a sense of guilt, remorse and/or inadequacy. Use of maladaptive coping strategies was high. Open-ended responses pointed to fear of retaliation, judgement, shame and retribution. Most residents disclosed their error to a senior resident but did not discuss it with the patient’s family. Only 32 % of residents participated in a debriefing session. Conclusions Most residents were directly involved in medical errors, which affected their emotional well-being. The use of maladaptive coping strategies was high. Residents’ fear of consequences prevented disclosure and discussion of self-perceived medical errors. This information is relevant to implement targeted interventions.
... Despite these potentially devastating outcomes, there is very little research in the area of trauma to forensic scientists from errors, and very few mental health resources available to them to get through these events [34]. The mental toll taken on doctors [35] and police officers [36] after errors has been studied, but research is needed to establish the extent of the toll taken on forensic scientists. ...
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... 10,11 The term ''Second victim'' was coined by Wu in the year 2000, the definition of which is: ''all professionals, providers of healthcare services, who are involved in an adverse patient event, medical error and/or a patientrelated injury which was unanticipated and converts them into a victim''. 12 Despite being a relatively recent issue, this has aroused great interest in recent years. 10,11,13 For those health professionals who suffer from it, this phenomenon may include pain, suffering, uncertainty, loss of reputation and negative repercussions on their health. ...
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... In addition to the commissioned papers and editorials by Dennis O'Leary (accreditation) [10], Jim Reinertsen [11] (disclosure), Michael Cohen (voluntary reporting) [12], and Albert Wu (second victim) [13], the final issue included 13 original papers and reports. ...
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To explore the emotional impact of the most memorable mistake on family physicians, the support they needed and received, and their response to a hypothetical scenario in which a colleague's decision was associated with a fatal outcome. Randomly selected members of a county chapter of a midwestern state academy of family physicians. Qualitative cross-sectional survey using in-depth interviews subject to content analysis. I audiotaped interviews with each of the physicians in their offices. Two medical sociologists and I first independently, and then consensually, categorized the data based on the frequency with which a word or idea appeared in the text. Thirty (75 %) of the 40 physicians originally contacted participated in the study. Twenty-three (77%) of the 30 physicians admitted to making a mistake. The physicians experienced emotional adversity. Of 27 physicians, 17 (63%) needed someone to talk to, 13 (48 %) needed to review their case management, 16 (59%) needed professional reaffirmation, and eight (30%) needed personal reassurance. Having someone to talk to was the support that 12 (44%) of the 27 physicians valued most. Eighteen (67%) of 27 received this support from someone other than their peers. Although all subjects recognized their colleague's pain and need for support in the hypothetical scenario, only nine (32%) of 28 physicians would have unconditionally offered support. Making mistakes unfavorably affects family physicians and creates a strong need for support. Family physicians may benefit from sharing experiences that diminish perfectionism and recognize mistakes as a natural part of practicing medicine. Further research needs to address how physicians can be encouraged toward therapeutic self-disclosure and peer support.
Healing the Wounds. A Physician Looks at His Work
  • D Hilfiker
Hilfiker D. Healing the Wounds. A Physician Looks at His Work. New York: Penguin; 1985.