“Delivery of healthcare, and perhaps especially surgery, is inherently stressful. When the outcome for the patient isn’t what was intended, it is easy to forget that the humans providing that care suffer as well,” said David E. Eibling, MD, a professor in the department of otolaryngology–head and neck surgery at the University of Pittsburgh in Penn., and chairman of the Second Victim Committee at the VA Pittsburgh. “Recognizing that one’s colleagues may be suffering following such an event requires insight and compassion, as well as willingness to offer support. The emphasis on such interactions should be on the individual, not the event. Expressing concern and listening are often the most important aspects of such interaction.”
Medical errors, which may have no adverse consequences or can be devastating for patients and their families, can also compound the work-related stress that physicians experience. Aside from medical malpractice lawsuits, the physical and emotional burnout related to medical errors is well-known. A 2007 study reported that physicians experienced increased anxiety, loss of confidence, sleeping difficulties, reduced job satisfaction, and harm to their reputation following medical errors (Jt Comm J Qual Patient Saf. 2007;33:467–476).
A Second Victim
“Any physician or surgeon who has made a medical error is at risk for anxiety and stress; surgeons may experience loss of confidence, sadness, shame, impaired sleep, loss of professional fulfilment, or clinical depression,” said Michael J. Brenner, MD, an associate professor in the department of otolaryngology–head and neck surgery at the University of Michigan Medical School in Ann Arbor. “Some surgeons will experience a post-traumatic stress disorder-type response to such medical mishap incidents.”
In an article published in 2000, Albert Wu, MD, a professor and director of the Center for Health Services and Outcomes Research at Johns Hopkins University in Baltimore, coined the term ‘second victim’ to convey that adverse events impact more than the injured patient (BMJ. 2000;320:726–727). The first victim of the event is the patient and their family, and the second victim is the caregiver involved in the event. Second victims can be residents, surgeons, nurses, or any health professional.
“At our recent presentation at the Triological Combined Sections Meeting, most respondents reported that if they had experienced the second victim syndrome, they still felt affected by the experience, reflecting the indelible mark left on surgeons when a patient suffers harm,” Dr. Brenner said.
Peter Weisskopf, MD, chair and consultant in the division of otology in the department of otolaryngology at the Mayo Clinic in Phoenix, explained that surgeons are trained to take “extreme responsibility” for everything related to their patients. They also have zero tolerance for errors. “These two factors can make any error seem like a huge black mark against you as a person. We internalize these and then are afraid to share them for fear of legal or social identification as a ‘bad doctor.’ This all feeds into the impostor syndrome that many physicians note,” Dr. Weisskopf said.
We internalize these and then are afraid to share them for fear of legal or social identification as a ‘bad doctor.’ This all feeds into the impostor syndrome that many physicians note. —Peter Weisskopf, MD
“Most of the common errors as described by the Agency for Healthcare Research and Quality (www.ahrq.gov) are systemic errors—that is, errors that involve more than one individual,” Dr. Weisskopf said. These require process improvement efforts and aren’t commonly something that a physician can fix alone. “Regardless, our sense of responsibility takes over, and we can become guilt-ridden and ineffective over our role in the mistake. The most personal errors—surgical mistakes would be a common one—can be even more devastating. This is where the stress of surgery comes to a head: ‘There is only one set of hands working on this patient, and I own them, so the error is entirely mine,’” Dr. Weisskopf said.
While resiliency and community can help in instances of medical errors, barriers exist. “Burnout, which seriously drains our resiliency reserves, is at an all-time high for surgeons. And in modern practice in the United States, our community may also be our competitors. Concern over legal jeopardy mutes our own self-evaluation and ability to discuss and process the incident,” Dr. Weisskopf said.
“Surgeons develop a moral injury as they try to balance the needs of legal, ethical, and personal response to the error. Being caught without an obvious solution may cause emotional paralysis, leading to inaction and a complete shutdown. The most extreme example would be the ‘shell shock’ described in World War I, where soldiers would simply freeze in place, feeling that there was no escape.
Nearly as bad would be a tendency to go to one extreme or another of responsibility. “Either convincing oneself that it ‘wasn’t really my fault,’ or that it was ‘completely my fault’ and believing that there’s no way to mitigate it in the future feels like ‘I failed,’” Dr. Weisskopf said. “Any of those responses prevents healthy examination of the incident and the ability to learn from it to become a better surgeon.”
Burnout
Physician burnout is associated with increased rates of self-reported errors. Burnout has been amplified during the COVID-19 pandemic due to increasing workloads, financial pressures, and challenging working conditions. “At the height of the pandemic, the stress and anxiety related to aerosol-generating procedures was a prominent feature. As the pandemic has receded in the United States, the pressures to increase productivity and recoup financial losses are compounded by supply chain disruptions and workforce shortages,” Dr. Brenner said.
Karthik Balakrishnan, MD, MPH, associate professor of otolaryngology at the department of otolaryngology–head and neck surgery at Stanford University in California, explained that burnout increases the risk of “effects of cognitive and implicit biases, and dehumanizing patients and colleagues. In turn, second victim effects can exacerbate burnout if not addressed thoroughly. Additionally, surgeons may tend to attribute errors to individuals rather than systems or processes, which makes this problem worse.”
Errors in otolaryngology take a variety of forms and can broadly be divided into blunt-end errors that relate to latent weakness in the system, involving problems with electronic health records, administrative processes, and design flaw, or sharp-end errors made by frontline clinicians related to direct patient care, Dr. Brenner explained. “Although both take a major toll on patients, attention tends to focus on the sharp-end errors, because it appears that a problem is attributable to the individual, even though system factors are often in play,” Dr. Brenner said.
Possible Solutions
According to Dr. Weisskopf, who previously served as a flight surgeon for the U.S. Navy, a possible solution to some of these issues can be found in the military, where mishap investigations are separate from either legal or criminal investigations, allowing witnesses and participants the ability to speak freely without concern that there will be legal consequences.
“The focus is on improving the process. Besides assisting with individual investigations, it develops a culture of process improvement and learning, with pilots discussing their errors and how they corrected them. A similar mindset in medicine might help doctors move away from a sense of personal failure,” Dr. Weisskopf said.
“In some institutions, there are structured approaches to help surgeons and other professionals respond to the trauma of patient harm. The most widely practiced is the Schwartz Rounds [www.theschwartzcenter.org/programs/schwartz-rounds/], which offer a forum to openly discuss the human dimension of care, including the social and emotional challenges. Other programs are tailored to promote resilience in stressful events,” Dr. Brenner said. “Such programs are the exception rather than the rule, however. Therefore, what’s most often needed is emotional first aid from peer supporters who actively listen, offer a compassionate presence, and provide support,” Dr. Brenner said.
What’s most often needed is emotional first aid from peer supporters who actively listen, offer a compassionate presence, and provide support. —Michael J. Brenner, MD
“Surgeons instinctively want to persevere—get through the workday or ‘tough it out’—but often the better approach is to identify a colleague who can cover clinical duties in the moment and take the healthful measures of getting adequate diet, sleep, and exercise. It’s also important to avoid excessive alcohol, caffeine, or other substances,” Dr. Brenner said. “Otolaryngologists trying to recover from error can benefit from structuring time to avoid rumination, doing things that bring joy, maintaining as normal a schedule as possible, and realizing that those around them are under stress too and can often empathize with their struggles.” Dr. Brenner added that follow-up and connection with colleagues are important, as silence or avoidance can worsen the pain or burden.
For many individuals, working to find a solution and prevent future events can help. “Many surgeons involved in quality improvement or implementation science were motivated by an adverse event during their career,” Dr. Brenner said.
Key Steps
Dr. Balakrishnan said that there are some key steps that can be taken to prevent the negative effects of having made a medical error. A morbidity and mortality conference can be a good place to start (Otolaryngol Head Neck Surg. 2018;158:273–279).
According to Dr. Balakrishnan, these steps include the following:
- Ensuring that our event reporting and review activities focus on system and process, not on individual blame. This encourages reporting by creating a climate of psychological safety.
- Using structured and facilitated forums to review events and identify opportunities for improvement, as well as long-term follow-up and “loop closure” (reporting back on these improvement activities).
- Separating review of provider performance from system and process review and ensuring that the former is supportive, focuses on improvement, includes effective coaching, and is kept confidential.
- As leaders, making sure that we support and implement these steps and submit to the same processes, so the rest of our teams feel safe doing so.
- Setting up robust wellness programs to support all clinicians, including those at risk for second victim effects.
“Healthcare is a socio-technical system, so we must examine systems and processes, individuals, and the interface between them, as well as how individuals interact with each other,” Dr. Balakrishnan said. “Disregarding any of these components will limit our ability to reduce errors and to cope with and learn from them when they do occur.”
Katie Robinson is a freelance medical writer based in New York.
Mishap Reports
While data on otolaryngology-related medical errors are sparse, here are some reports on medical mishaps in the profession:
Medication
Of the 534 members of the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) who responded to a 2021 online survey, 25% reported at least one patient safety event in the past 10 years. The study, which focused on intraoperative sentinel events, reported that medication errors were the most common type of error, while wrong site or procedure, retained surgical item, and operating room fire were also reported as medical errors (OTO Open. 2020;4:2473974X20975731).
Perioperative and Airway Management
Perioperative and airway management errors were reported more frequently in otolaryngology compared with other inpatient and outpatient departments across hospitals, according to a 2020 study. Otolaryngology departments reported lower proportions of events related to diagnosis and treatment, laboratory results and specimens, medication and fluids, and safety and security, however. In otolaryngology, the most reported adverse events occurred perioperatively, followed by issues concerning equipment and medical devices (Laryngoscope. 2021;131:509–512).
Misjudgment
Adverse events aren’t infrequent in facial plastic surgery, a 2021 study reported. The researchers surveyed 253 members of the AAO-HNS and American Academy of Facial Plastic and Reconstructive Surgery. While surgeon misjudgment or patient non-adherence were commonly cited, systems-based factors were rarely reported as reasons for adverse events (Am J Otolaryngol. 2021;42:102792).
In 2020, national data showed that over half of otolaryngologist respondents in the United States reported instances of attempted oral intubations among patients with laryngectomy, with a mortality rate of 26%. Most of these errors occurred in otolaryngology patients, but the errors were not made by otolaryngologists (Otolaryngol Head Neck Surg. 2021;164:1040–1043).