What Science Tells Us! The Multiple Victims of Medical Errors

 Medical errors are a serious public health problem and rank as the third leading cause of death, following heart disease and cancer.

— @TheKnowHow

What Science Tells Us!

The Multiple Victims of Medical Errors

Medical errors can create a domino effect of harm that impacts many people. Understanding the multiple victims of errors and ways to prevent them is essential for improving healthcare outcomes.

The Impact of Medical Errors

Medical errors are a serious public health problem and rank as the third leading cause of death, following heart disease and cancer. Every day, healthcare professionals (HCPs) practice their skills and knowledge within excessively complex situations, often encountering unexpected patient outcomes. These unforeseen complications and unintentional errors will always be part of the medical system.

The Rights of Patients

Not all negative outcomes are preventable, and not every complication results from mistreatment. However, medical errors can happen and may significantly compromise a patient’s quality of life. Ensuring patients have access to safe, reliable, and patient-centered care is a critical and primary aim of medicine.

Beyond the Patient: The Ripple Effect

The victims of medical errors extend far beyond the patient. The concept of the “second victim” (SV), first described by Albert Wu, highlights the impact of errors on healthcare professionals. This medical emergency is equivalent to post-traumatic stress disorder for HCPs. When an error occurs, it can trigger a domino effect involving four groups:

• First Victim: The patient and their family.
• Second Victim: The healthcare professional involved in the error.
• Third Victim: The hospital’s reputation.
• Fourth Victim: Patients who are harmed subsequently.

What is Second Victim Syndrome?

The second victim syndrome (SVS) is defined by the psychological, cognitive, and physical reactions manifesting in health care professionals who commit an error.

The relevance of medical errors and multiple victims from it is high: As much as every firth of hospitalized patients may experience a complication. After such an adverse event, between 10–40% of doctors, nurses or other healthcare professionals react traumatized. Almost half of healthcare professionals experience the impact as a second victim at least one time in their career. These numbers might even be higher, because doctors often keep silent because of the fear of litigation or the absence of a well-defined error reporting system. The effects are seen particularly strong among physicians specializing in surgery, anesthesiology, pediatrics, or obstetrics and gynecology, where medical errors more frequently are threatening the life of the patients or may result in life-long disability and suffering.

Naturally, everyone will react with sorrow or shock, when a patient suffers or dies within an unexpected complication. When the affected persons have good coping strategies and external support from their institutions, they may find a constructive way to deal with the consequences and are back to an improved work soon.

Second victim syndrome (SVS), however, presents with prolonged emotional consequences and affecting the personal life and professional practice. Whether the complication is a result of a personal error of an inevitable event, “second victims” may feel shame, guilt, anxiety, grief, or depression. They may react with a lack of empathy to protect themselves from the negative emotions. Others may show signs of burnout or posttraumatic stress being hunted by flashbacks and nightmares about the adverse event. Frequently, SVS results in social (self)isolation, nagging doubts and lowered self-esteem. The psychological effects also impact the physical health, with disturbed sleep, concentration problems, and vegetative symptoms such as high heart rate, hypertension or gastrointestinal problems.

As a result, SVS may have a long-term effect on the profession of the affected healthcare professionals.

Second Victim Syndrome in Research

The team of Chong and Yaow from Singapore analyzed published data on SVS in surgical settings and reviewed thirteen qualitative studies conducted in the United States, the United Kingdom, Canada, and France.

Guilt was the most commonly and the most persistent negative expressed feeling, because of the unique relationship that surgeons have with patients, primarily based on responsibility. It was sometimes associated with intense reminiscences about complications encountered in the past and amnesia of names, families, and faces. Furthermore, guilt often coincided with depressive symptoms.

Anxiety was also frequently described as disturbing, invasive, and restless. It was often associated with anger and frustration and sometimes manifested as rudeness toward patients or the operating room team. Beyond provoking negative feelings, an error or the occurrence of a complication affected judgment and self-confidence, leading to rumination and questioning of what could have prevented the complication.

SVS impaired professional performance of the surgeons, led to avoidance behaviors, and often had medical-legal or disciplinary implications. Most surgeons believed that their professional behavior had not been optimal, and this judgment frequently resulted in the cessation of certain activities or types of interventions, with this conservative attitude sometimes to the detriment of patients.

Surgeons were concerned about their reputation and suffered from professional dissatisfaction, especially given the prevalent criticism and condemnation in this highly competitive environment. The perception of a lack of support from peers was amplified by the absence of support from hospital institutions, with the fear of seeing their positions questioned.

“M&M”s — Learning From Errors vs Culture of Blame

Healthcare systems and facilities have established a structured review of adverse events called “M&M”s: Regular Morbidity and mortality (M&M) conferences are recurring conferences held by medical services at academic medical centers, most large private medical and surgical practices, and other medical centers. Death (mortality), deterioration and complications (morbidity) may be unavoidable in some patients due to underlying disease processes. However, they may also be associated with errors or omissions in patient care.

M&M conferences involve the analysis of adverse outcomes in patient care through other experienced physicians. The objectives of a well-run M&M conference are to identify adverse outcomes associated with medical error, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications. Conferences are meant to be non-punitive, focus on the goal of improved patient care, and are often governmental regulated (details are available public UAE, MoHAP).

At least, that is the well-meant theory behind M&Ms.

The analysis of Dr. Joël Pitre published in March 2024 in the French JIM.fr (Journal International de Médecine), suggests a another grim scenario. In an often competitive and reportedly unsympathetic environment marked by easy criticism, the established M&Ms were experienced by some surgeons as an opportunity for public blame instead of a source of learning and improvement. As a result, surgeons remained on the defensive, cutting the dialogue short.

Even if the atmosphere could be constructive, the debate was mainly focused on technical issues rather than on psychological consequences. Finally, the lack of administrative support was emphasized, contributing to this culture of blame, with mainly punitive responses and without analysis of the underlying systemic causes.

A Change in Culture

As tragical a surgical complication is, it may force surgeons to rethink and reflect on their roles, as well as that of their service and institutions. On an individual level, some surgeons said that they became more cautious, more vigilant, and better understood safety issues. At the service and institutional level, improvements were noted in procedures, protocols such as checklists, timeouts, and equipment check.

According to the analysis of Chong and Yaow, physicians asked for a structured support: a defined break from their activities, discussions with colleagues to facilitate communication with patients, and formal psychological assistance. When this type of help was standardized, the atmosphere during M&Ms was much calmer. Exchanges with colleagues were by far considered the most effective help (81%), especially for younger individuals. Meanwhile, several leading institutions have reacted to reduce second, third and fourth victim events and developed formal support programs that allow healthcare professionals to cope with their emotional distress by obtaining timely support in an emphatic, confidential, non-judgmental environment.

However, culture change is more than structured report and support. Trust has always been the basis of the doctor–patient relationship. Trust has been shown to be important in its own right. It is essential to patients, in their willingness to seek care, their willingness to reveal sensitive information, their willingness to submit to treatment, and their willingness to follow recommendations. The culture of “shame and blame” aimed at healthcare professionals endangers a trustful relationship between patients and doctors.

A Trusted Doctor

Patients may perceive their doctors as infallible experts. Physicians similarly tend to expect the same unrealistic levels of perfection from themselves. Although it is often said that “doctors are only human”, developments in medical technology and the greater precision of laboratory tests in fact generated an expectation of perfection. However, medicine is not always perfect, and can never have complete validation for each treatment for each single patient.

The humbler the medical profession is, the more likely it will avoid (reoccurring) errors and regain trust. Studies showed that full disclosure of errors to patients and their families is associated with greater trust, higher satisfaction, more positive emotional response, less support for sanctions against the physician, and less probability of changing physicians. Ethical and honest behavior helps regaining trust — even after an error event.

Second Opinions — To Heal and to Prevent

A review of Dr. Herring in Journal of Pediatric Orthopedics shows that bringing in a colleague to see the patient afflicted from a medical error and discussing the event can be helpful. A second opinion is part of an open review — and may be the start of the healing process for the second victim doctor.

Preoperative conferences or interdisciplinary tumor boards are also important in the prevention of complications. When several physicians discuss their upcoming cases, many pitfalls can be avoided. Patients often appreciate that these discussions resemble multiple “second” opinions. If such conferences are not regularly available, doctors may encourage their patients to seek a second opinion of an independent expert — either for reassurance or modifying the treatment strategy. Any indicated changes of the plan are usually a welcomed resource to enhance patient´s safety and outcome.

As a result, second opinions represent reassurance and (re)gaining the trust of patients.