1. Clinical Errors & Second Victims
I used the term “Clinical Errors” as this applies equally to nurses & allied health staff as well as medical staff and this was a multi-disciplinary meeting (M&M) where it was presented.

2. Clinical Errors Photo credit:
In recent years, there has been a huge Patient Safety movement in hospitals, which whilst beneficial for patients, has had an unquantifiable impact on the wellbeing of the staff involved in these errors.
Errors will always occur in medicine. Diseases are complex, patients do not always present in textbook fashion. Errors will always occur as all the individuals in the system are human, and humans make mistakes. Significant errors are thought to occur in up to 3% of hospital presentations in the USA. No one comes to work wanting to cause harm to patients, however the reality is at some point in our career we will be involved in a medical error.

3. Do you remember that patient you saw
Do you remember that patient you saw? I think these words put fear into anyone who works in healthcare. It is not usually because the patient came back and left you flowers & chocolates in the tearoom.

4. The impact of finding out that you have been involved in an adverse event can be devastating. Albert Wu coined the term Second Victim in an article in the BMJ in It describes how, without the right support, it is possible for the healthcare worker to become the second victim. This can have long term affects on their wellbeing and their work with future patients.
If their ability to confidently diagnose and treat patients becomes affected, the next patient that they see may become the third victim. They may develop a tendancy to avoid patients with similar pathology, or over-investigate to prevent missing another diagnosis. This may continue for many years into the future.
They then carry this impact home with them and their spouse or family members become the fourth victims.
It is important that we provide support to staff involved in clinical errors so that they don’t become victims themselves.

5. The effect of medical errors on the health professionals involved ranges from feelings such as sadness, guilt, shame and fear of criticism, to helplessness, loss of self-confidence and anxiety & depression. They have shown to impact how individual clinicians practice medicine even years later in their career. How we deal with these inevitable mistakes when they occur is important to the long-term wellbeing of our staff.

6. .
There are a few stages to recovery for a clinician involved in a clinical error. There is the initial event with the chaos that occurs. The next stage is the intrusive reflection stage where the individual may have intrusive thoughts about the case, even keeping them awake at night. They may lose confidence and avoid colleagues due to the feeling that they have been judged by their workmates. This may improve in stage 3 with time and support to only resurface again months later when the investigation into the case occurs. This can be many months down the track and often brings back all of those initial emotions about the case again. By this stage, the support network in the workplace has often forgotten about the case, so the individual suffers this phase alone unless they seek out help. Stage 6 shows that this can end in a number of outcomes ranging from staff leaving clinical practice, to just surviving but carrying the scars with them throughout their career to the ideal outcome, moving forward and thriving from what they have learnt from the case. The key to determining which of these outcomes occurs is in the support networks provided throughout these phases.

7. I posed this as a question to the audience
I posed this as a question to the audience. “What are the barriers to seeking help after clinical errors in our department?” This generated good discussion and included answers such as: Time pressure to get on and see the next patient not allowing any time to debrief, fear of admitting mistakes, not knowing where to access support, not having a formal process in the department, and from trainees, not wanting to appear weak and unable to cope as this may affect training and assessments.

8. (Photo: Dawn Lim) http://www. uhn
After a big resuscitation there is usually a scramble to clean up & get ready for the next patient, to comfort the family and complete documentation. How often do we stop and check that everyone in the team is OK? Often we have a brief “hot debrief” to discuss the clinical issues that arose during the event. Often the only formal debriefing occurs weeks or months later as part of an M&M meeting. Even when a resus has gone well, don’t forget to consider the impact on junior staff such as medical students as it might be the first time they have seen someone have CPR or die.

9. Critical Incident Debrief
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There are well recognised ways to mitigate the risk of becoming a second victim after an adverse event. Organisations need to have an inbuilt support structure in place to support their staff during these events. This might include mentors, meetings with supervisors or formal debriefing processes. Debriefing with colleagues is an effective way of dealing with the stress of a critical event or error. Most departments do not have formal debrief structures in place to accommodate this for their staff. It is important to recognise that debriefing is not just for bad outcomes and big resuscitations, there may be significant impact on a junior doctor from finding out about a minor error such as a missed fracture. It is important to offer a support structure in your department for all these types of situations and for all staff.

10. Blame vs Just Cultures
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There is a great book called “Black Box Thinking by Matthew Syed – which discusses the concept of a growth mindset and learning from our mistakes in order to get better. I would highly recommend reading this for anyone involved in healthcare. The purpose of mistakes is to learn from them. Any mistakes that we cover up, we don’t have the opportunity to explore and learn from.
An organisation with a blame culture, singles out individuals involved in errors and makes them feel blamed. They may discuss errors in terms of systems issues but the individuals are still made to feel ashamed. This culture discourages people from admitting their mistakes and creates a culture of cover ups of medical errors.
In comparison, a just culture is one where the individuals are encouraged to speak up and learn from mistakes and that the individuals is praised for speaking up and encouraged to be involved in making the organisation safer. This is different to a no blame culture, as there is still accountability for individuals who are working outside of acceptable norms, however for most, it encourages a no blame culture of learning and improving.

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