Learning Objectives:
After reading this article, you will be able to:
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Define secondary or occupational trauma.
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Describe the effects of medical errors on care providers.
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Identify strategies used to help cope when medical error occurs.
Case Study
It was a busy night in the ER and the patient with strep throat was the least of the doctor’s worries–until the patient developed anaphylaxis. In her haste to treat the patient, the doctor gave a penicillin injection without noting a prior severe reaction to amoxicillin had been documented. Within moments of the injection, the patient began having trouble breathing. The mistake was quickly realized and treatment begun, but the patient still required intubation and several days in the ICU. The patient survived, but the doctor was left wondering how she could have made such an error. She worried it was only a matter of time until it happened again. What is happening?
Medical error and secondary trauma
strive for perfection in the care we provide, but, despite our best efforts, errors do happen–patients do get hurt. While initial concerns correctly turn to caring for the patient, we need to also address the feelings of guilt, shame, and anxiety that care providers feel when things go wrong. Family practice physician David Hilfiker first described the devastating effects of medical error on caregivers in his powerful 1984 New England Journal of Medicine article, “Facing Our Mistakes.” (1) This experience has come to be defined as secondary or occupational trauma, describing a health care provider who feels significantly impacted or traumatized by the adverse event. (2-4) The care provider is left to cope with feelings of guilt, shame, and anxiety while also questioning their competency to provide care in the future.
Effects of secondary trauma
Health care providers who experience secondary trauma report feeling:
- Hopeless/helpless
- Disconnected from others
- Extreme fatigue
- Difficulty falling/staying asleep
- Exaggerated startle response
- Easily irritated/feel on edge
- Decreased job satisfaction
- Increased substance use
- Fear of future errors and decreased confidence in skills
Impact of secondary trauma on health care providers
It’s estimated that 10-40% of care providers will experience secondary trauma. As a result of the stress, health care providers have reported symptoms related to depression, burnout, and post-traumatic stress disorder. In addition to the harm incurred by the provider, these feelings may also negatively alter the provider-patient relationship. There’s also an indication that these feelings may affect future event reporting, curbing system-wide improvement. (3, 5)
Coping with the stress of a medical error
Following a medical error, a health care provider may go through a series of stages of recovery that will ultimately see them find ways to cope and continue on in their practice, or leave their career.
Stage How it works Questions asked
| 1. Chaos & Accident Response | Medical error is realized and efforts are focused on getting help to the patient. |
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| 2. Intrusive Reflections | Events are re-enacted and providers begin asking “what if” questions while coping with early feelings of inadequacy. |
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| 3. Restoring Personal Integrity | Seek confidence from trusted peers and begin to worry whether the trust of other peers can be regained. |
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| 4. Enduring the Inquisition | External repercussions that could lead to litigation or affect future career prospects and licensure. |
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| 5. Emotional First Aid | Providers seek emotional support through personal, professional, or institutional avenues. |
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| 6. Moving On | Providers may “drop out” due to stress and self-doubt, “survive” with lingering stress, or “thrive,” reporting growth and learning from their experience. |
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Figure 1. Six stages of secondary trauma. Adapted from Scott et al, BMJ 2009.
Strategies to address secondary trauma
Take care of yourself
Strategies that have been demonstrated to increase resilience and prevent burnout can also be utilized to prevent second victim syndrome, such as using simple mindfulness strategies, exercising regularly, engaging in meaningful activities outside of work, having supportive relationships, and addressing routine health needs.
Know what to expect
Health care providers can also benefit from learning what to expect cognitively, emotionally, and physically following an error. It is normal to experience difficulty concentrating, repetitive thoughts related to the error, sleep issues, headaches, stomach or back pain, and feelings of sadness and guilt for a few days following the error. Expect these symptoms–do not treat them as signs of weakness or being an unskilled provider.
How to support others
As a team leader, you can address secondary trauma by establishing and maintaining a culture of support and by becoming familiar with local resources, such as U of U Health’s Resiliency Center. The Resiliency Center provides confidential screening and access to a number of services that foster wellness and resilience for all employees at U of U Health.
As a peer. Clinicians are overwhelmingly more likely to seek support from peers instead of mental health professionals or Employee Assistance Programs (EAPs). By listening and providing supportive comments, colleagues can talk through the error, understand why it occurred, and better cope with the emotional stress. Because peer support is so important to recovery, formal peer support networks to address secondary trauma have been initiated at organizations across the nation, including U of U Health. (3, 4)
Conclusion
No single strategy exists to ensure recovery from occupational trauma. It is important to talk to peers while not minimizing the events and stresses experienced. The doctor in the opening case was lucky–her hospital had a system in place to proactively reach out to physicians involved in medical errors and pair them with peers for support. As a result of her involvement in a root cause analysis of the event, she was able to help redesign the medication administration procedure in the ER to improve recognition of allergies. While she still thinks of the event when she places medication orders, she was able to use a well-developed peer support network and create positive change at her hospital.
References
- Facing Our Mistakes (NEJM 1984) David Hilfiker’s landmark article is 34 years old, but it still resonates due to its blunt acceptance of the inevitability of making serious mistakes as a physician.
- Medical Error: The Second Victim (The BMJ 2000) Today's belief that constructive intervention with respectful empathy can prevent future errors stems from Albert Wu's identification of the second victim phenomenon: "The doctor who makes the mistake needs help too."
- Health Care Professionals as Second Victims After Adverse Events (Eval Health Prof 2012) Seys et al conduct a systematic literature review of the second victim concept, identifying the steps necessary to support providers and make improvements after adverse events occur.
- The role of talking (and keeping silent) in physician coping with medical error: a qualitative study (Patient Education and Counseling 2012) Natalie May and Margaret Plews-Ogan research the way that physician discussions about medical errors are associated with the ability to recover.
- Physicians' Needs in Coping with Emotional Stressors: The Case for Peer Support (JAMA Surgery 2012) Hu et al argue that, despite the prevalence of stressful experiences and the desire for support among physicians, established services are underused — and that peer support is the most effective way to address the issue.
Resources
This article was originally published September 2018.
Brian Flaherty
Megan Call
Workplace aggression occurs so frequently in health care that it’s often accepted as “part of the job.” Patient Safety nurse coordinator Connie Phelps describes some of the work being done at University of Utah Health to help shift that paradigm.
For National Injury Prevention Day, Spencer Steinbach, Senior Nursing Director, discusses safety and injury prevention in nursing and the outdoors and shares tips for your next adventure.
Varsha Iyer is an inpatient child and adolescent psychiatrist at Utah’s University Neuropsychiatric Institute. Here she shares both individual and institutional advice on dealing with the chronic stress of racism and the acute stress of COVID-19 to lead the way for positive, enduring change.
