CARING FOR THE CAREGIVER: MOVING BEYOND

THE FINGER POINTING AFTER AN ADVERSE EVENT

Author: Susan Paparella, MSN, RN, Horsham, PASection Editor: Susan Paparella, RN, MSN

Earn Up to 9 CE Hours. See page 301.

Primium Non Nocere. This well-known Latin phrasefor “First…Do No Harm” is a time-honored stan-dard in health care. Some historians attribute this

saying to Hippocrates, and while this fact cannot be sub-stantiated, this theory of nonmaleficence was lateradopted into American and British medical culture.1

While the true origin of this phrase is often challenged,this moral imperative in health care has remained stead-fast throughout the centuries and lends itself to a profes-sional expectation of perfection in the health carecommunity. Perfection in all aspects of health care alsohas become a societal expectation over the years, and itcreates significant challenge to the health care communitywhen an error or adverse event does occur. Although noone would argue that it is acceptable to knowingly andpurposely harm patients, the common tenet of health careperfection that “good nurses (pharmacists, or physicians)don’t make errors,” which often is perpetuated by thelegal community, the media, and sometimes even ourown profession, is an unrealistic standard to uphold. Inreality, because “to err is human,” error-free health care

is fundamentally unattainable as long as human beingsare involved in its delivery. It is this struggle betweenour basic beliefs and desire for perfection in our workand the reality of “being human” that creates a cognitivedissonance or moral conflict for providers and in manyways influences our response to harmful events.2

The nurse’s response to adverse events has been stu-died for many years by researchers including Crigger,Meek, and Wolf 2,3 Because the desire for perfection isso closely tied to our self-image as a good practitioner, indi-viduals learn how to successfully “redefine” or “rationalize”less harmful errors when they occur. Nurses are known toconstruct a logical justification for their decision or learnearly in their career how to “get an order” to fix an unde-sirable situation and to make it a “non-error.” It also ismuch easier to admit to ourselves that we made a mistake(which requires an altered view of self), especially if noharm was involved, than it is to say that we hurt someoneelse (which would be against our moral imperative).2

The responses of persons involved in harmful errorsand adverse drug events are predictably more personal.These nurses report initial symptoms of shock, anger,denial, and despondency. They often go through stagesof bargaining, guilt, and regret of their actions.2-4 Practi-tioners involved in error fear the loss of their reputation,jobs, income, licensure, and even more recently, the crim-inalization of the event with felony indictments.5

Because errors are not as rare as the health care com-munity would like the public to believe, most practicingnurses have had experiences with an error themselves orhave been closely associated with a harmful event. As ahealth care community, we have improved our responseto error by early disclosure to patients and families andthe rigorous system analysis that can be accomplishedthrough root cause analysis. But what about the practi-tioners involved? How do we help them cope? What is cur-rently in place in your organization to support the providerafter an event?”

Historically, the punitive approach to errors in healthcare has been to “Name,” “Blame,” “Shame,” and “Retrain”the individual(s) involved in the error. Instead of carefullyexamining the safety system issues that may have contrib-

Susan Paparella, Member, Bux-Mont Chapter, is Vice President at theInstitute for Safe Medication Practices (ISMP*), Horsham, PA, and a mem-ber of the Advisory Committee for the Institute for Quality, Safety, andInjury Prevention.

*ISMP is a nonprofit organization that works closely with health care practi-tioners, consumers, hospitals, regulatory agencies, and professional organiza-tions to educate caregivers about preventing medication errors. ISMP is thepremier international resource on safe medication practices in health careinstitutions. If you would like to report medication errors to help others,E-mail us at: ismpinfo@ismp.org or call (800)FAIL-SAF(e). This MedicationError Reporting Program keeps information confidential and secure. We willinclude only the level of detail that the reporter wishes in our publications.

For correspondence, write: Susan Paparella, MSN, RN, The Institute forSafe Medication Practices, 200 Lakeside Dr, Suite 200, Horsham, PA19044; E-mail: spaparella@ismp.org.

J Emerg Nurs 2011;37:263-5.

Available online 4 April 2011.

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Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.

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uted to the error in the first place, staff are told to “bemore careful” and “follow the five rights.” Remediationfor one individual is often a punitive response and will notprevent the error from recurring. As health care providers,we are particularly good at pointing a finger at our own co-workers and at other disciplines, often as a knee-jerkresponse, without fully investigating the event and contri-buting factors. This critical approach has never proved tobe effective for problem solving and error reductionand clearly lacks empathy and respect for others. Sadly,studies show that the professional who makes the errorwill receive more unsupportive reactions than actualsupportive reactions from health care peers and super-iors.4 Sometimes co-workers have been asked not tospeak to the individual involved in the error, and thusthese “second victims” have felt abandoned by the sys-tem itself. It is almost like we take the approach“Guilty until proven innocent.”

The “second victim” is a term that has been coined byWu6 to describe the health care professional(s) involved inthe serious event. Such individuals feel as if they have per-sonally “failed the patient.” Other studies describe symp-toms that are similar to post-traumatic stress disorder.The physical and emotional response is often so severe thatpractitioners experience chronic physical and psychologicalsymptoms and begin to second guess their clinical skills,knowledge, and even their career choice. If the situationis unresolved, severe depression and suicidal thoughtsmay follow. To add insult to injury, co-workers are oftenquiet about the event and may ignore the situation in thebelief that their colleague may not want to talk about it.This isolating behavior adds to their feelings of mistrust,guilt, and abandonment. They begin to believe they areunworthy of our attention and concern.4

It is important for us as health care providers to alsocare for the caregiver when a serious event occurs. As withthe stress management strategies used in critical incidentdebriefing, staff must learn the best way to support provi-ders who also may feel victimized in the error. It has beenthe experience of the Institute for Safe Medication Practices(ISMP) that most organizations have a sentinel event planbut do not have a defined strategy in place for supportingthe employee who was involved beyond referral to anemployee assistance program.

One organization that understands this obvious gapin our approach to individuals involved in error and thatsuccessfully implemented a support program is the Uni-versity of Missouri Health System under the guidance ofthe Office of Clinical Effectiveness. They recognized thatmany of their staff were being affected more than theyimagined. They embraced this new understanding and

developed a rapid response team of sorts to anticipateand react to the needs of second victims, aptly calledWounded Healers.4,7 The organization has developed amodel of trained providers to respond immediately tothe needs of the health care provider to help him orher through what they term “Six Stages of Recovery.”The volunteer team helps the second victim navigatethe initial chaos and accident response, avoid intrusiveself-reflection, restore personal integrity, ensure safetythrough the inquisition, obtain any needed emotionalfirst aid, and eventually get to a point of resolution.

Just as we initiate a standard approach and much-needed investigation and analysis following a serious event,let us remember to also initiate a set of deliberate andfocused actions to better support our employees who maybe the second victim(s). Emergency departments can starttoday by creating awareness for staff of the typical “secondvictim” responses and promote an open dialogue about theissue or error. Nursing directors in the emergency depart-ment can begin the dialogue by asking an easy question pro-posed by Denham, “Have you had a patient safety issue inthe last year that has caused you anxiety, depression, or aninability to perform your job?”8 In Scott’s research of thistopic, 1 in 7 practitioners said yes to this query, and 68%of these said that they did not receive institutional help.7

As ED nurses who are trained in crisis intervention and man-agement, we should be able to do much better than that forour own co-workers. Using accountability models such asJust Culture that help us define practice expectations, consolepersons who commit human error when it is unavoidable, orcoach at-risk behavior is a much better approach when qual-ity and patient safety are at risk.9

Do not be afraid to use proven methodology to dealwith stress when creating internal support mechanisms. Asa start, become familiar with a group called Medically-Induced Trauma Support Services (MITSS) (http://www.mitss.org/aboutus_home.html). Their mission is to createawareness, promote open and honest communication, andprovide services to patients, families, and clinicians affectedby medically induced trauma. A self-assessment tool thatcan be used internally in your emergency department tounderstand the nature and perception of current organiza-tional support can be found at http://www.mitss.org/MITSS_Staff_Support_Assessment_Tool.pdf.10

Let us not forget that our ED colleagues who havebeen involved in a serious adverse event face a myriad ofemotion, not the least of which is often a lifetime ofguilt and regret. If we truly are “caregivers,” then weare long overdue to move beyond the finger pointing andinappropriate punishment of these “second victims” andtreat them with the support and respect they deserve, in

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an environment of compassion and transparency. If wecan get beyond the finger pointing, then we can thenget back to the serious work of error prevention andpatient care.

REFERENCES1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 4th ed.

New York, NY: Oxford University Press; 1994.

2. Crigger NK, Meek VL. Toward a theory of self-reconciliation fol-lowing mistakes in nursing practice. J Nurse Scholarsh. 2007;39(2):177-83.

3. Wolf ZR. Health Care Providers’ Experiences With Making Fatal Medica-tion Errors. Washington, DC: American Pharmaceutical Association;2007.

4. Scott SD, Hirschinger KR, Cox M, McCoig J, Brant J, Hall LW.The natural history of recovery for the healthcare provider “secondvictim” after adverse patient events. Qual Saf Health Care. 2009;18(5):325-30.

5. Smetzer J, Baker C, Byrne FD, Cohen MR. (2010) Shaping Systems forBetter Behavioral Choices: Lessons Learned from a Fatal MedicationError. Jt Comm J Qual Patient Saf. 2010;36(4):152-63.

6. Wu A. Medical error: the second victim. The doctor who makes mis-takes needs help too. BMJ. 2000;320:726-7.

7. Scott SD, Hirschinger KR, Cox M, et al. Caring for our own: deployinga systemwide second victim response team. Jt Comm J Qual Patient Saf.2010;36(5):233-40.

8. Denham CR. TRUST: The 5 rights of the second victim. J Patient Saf.2007;3(2):107-19.

9. The Just Culture Community. Just Culture Web site. http://www.justculture.org/. Accessed January 11, 2011.

10. Medically-induced Trauma Support Services Web site. http://www.mitss.org/aboutus_home.html. Accessed January 10, 2011.

Submissions to this column are encouraged and may be sent toSusan Paparella, RN, MSNspaparella@ismp.org

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