Error is almost inevitable in our clinical practice so we should be prepared to help and prepare those individuals involved for the benefit of them, our systems and our patients.
Do you remember that patient you saw last night?': A phrase the strikes terror into the hearts of all physicians. The prospect of a patient coming to harm as a result of a mistake is terrifying but it can and does happen.
The consequences for the patient and their family are often tragic but what of the clinicians who made the error? For many the result of making a terrible error is life changing.
Those permanently harmed by error are often referred to as second victims with the consequences of terrible events being life-long.
This talk explores the predictable course for clinicians who are involved in error and asks whether we can prepare and support such individuals through a difficult time.
17. Medical Error: the secondVictim A.Wu. BMJ 2000
Second victims are healthcare 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.
Frequently, these individuals feel personally responsible for the patient
outcome. Many feel as though they have failed the patient, second
guessing their clinical skills and knowledge base.
18. Medical Error: the secondVictim A.Wu. BMJ 2000
Second victims are healthcare 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.
Frequently, these individuals feel personally responsible for the patient
outcome. Many feel as though they have failed the patient, second
guessing their clinical skills and knowledge base.
45. In no relationship
is the physician
more often
derelict than in
his duty to
himself (herself).
46. monitor incidents
contact supervisors
Mentors
Parallel support for second victims
Other things -
develop emotional understanding
Schwartz rounds - build emotional and
psychological understanding of how people
feel not just what happens.
Organisations
48. Organisations
Contact clinical sta๏ฌ
Rea๏ฌrm your con๏ฌdence
Give time and space
Keep informed
Let them know you care
Be visible to all sta๏ฌ members.
Teach resilience
Guide donโt dictate
49. Clinicians get harmed too
You may become a second victim
You will certainly meet second victims
There is a predictable course to recovery
You can personally prepare
You can organisationally prepare
You can personally support
You can organisationally support
53. โa health care provider involved in an unanticipated adverse
patient event, medical error and/or a patient related-injury who
become victimised in the sense that the provider is
traumatised by the event.
54. โa health care provider involved in an unanticipated adverse
patient event, medical error and/or a patient related-injury who
become victimised in the sense that the provider is
traumatised by the event.
Frequently, second victims feel personally responsible for the
unexpected patient outcomes and feel as though they have
failed their patient, and feel doubts about their clinical skills
and knowledge base.โ