The main findings of the present study, which investigates the impacts of MEs on a sample of North-African physicians, were the following: i) 68.2% of physicians encountered a ME, ii) 84% of physicians reported not knowing the term “second victim”, iii) wrong diagnosis, faulty treatment, preventive errors and faulty communication were the main types of MEs, iv) the two common causes of MEs were inexperience and job overload, v) female sex and involvement in serious MEs were identified as predictors of PTSD, and vi) MEs had significant impacts on physicians’ behavior (ie; most of physicians reported constructive changes, namely, reading, asking superiors, and paying more attention to details).
In 2000, Albert Wu (22) coined the term “second victim” to describe the emotional response of clinicians to MEs. This term has since been used to describe healthcare providers who experience difficulties to cope with their emotions after MEs and who may suffer in silence (8,23). According to Denham et al. (24), care providers can be psychologically harmed by unintentional MEs while trying to help patients. If harmed patients and their families are considered “first victims”, “second victims” are the caregivers involved in those unintentional MEs. Furthermore, he considered as “third victims” the health care organization harmed by leaders’ behavior.
Several instruments have been developed to measure PTSD symptoms after traumatic events, but the IES-R was the first instrument developed for this purpose and the most widely used self-report scale. The French version used in the present study was validated in 2003 (19) with good internal validity and test retest reliability to assess post-traumatic stress reactions. The strengths of this tool are that it is short, simply administered and scored. It corresponds better with the “diagnostic and statistical manual of mental disorders” criteria for PTSD, and can easily be used repetitively. The ways of coping checklist WCC-R was translated to- and validated in- French with good psychometric properties (25). It is a brief (5 to 10 minutes) self-reported tool (25).
In the present study, 57 of respondents refused to answer the questionnaire. It may be that professionals who responded had been notably more affected by serious/severe events and their related problems than their non-responding colleagues. However, non-responders could also be considered as the most severely affected group by traumatic events; they may have found the survey too personal or emotionally disturbing hence their abstinence from participating.
Frequency of MEs
MEs are common, and most clinicians are likely to make them at least once in their careers (26). In the present study, only 68.2% of respondents reported prior involvement in a ME. This could be integrated as a severe psychological impact in those responders reporting no errors, meaning they never coped with their errors. As those responders were younger and less experienced this result could be otherwise related to the short period of exposure. First, this was in line with a previous study reporting a frequency of 67% (27). Second, lower frequencies of MEs were reported by some authors (8,28). For example, Lander et al. (28) analyzed otolaryngologists’ responses to ME and reported 10.4% of MEs, and Scott et al. (8) who analyzed psychological, emotional and professional support for health care providers noted 30%. Third, a higher frequency was reported by Garbutt et al. (15) who noted that 97% of pediatricians were involved in serious MEs. Discrepancies in rates could be explained by sincerity in response to questionnaires, methodological differences, and cultural influence in reporting errors. In this study, 42.5% of respondents reported prior involvement in serious MEs. Similar findings were noted in different studies reporting serious MEs resulting in deaths in 31% (18), 34% (29) and 39% (30) of cases.
Causes of MEs
In this study, inexperience (47.3%) and job overload (40.2%) were the most selected reasons for MEs reported by physicians. This finding is consistent with results from a survey conducted by Wu et al. (18) who highlighted that 54% of house officers attributed MEs to inexperience and 51% reported job overload. Other studies provided same assessment of causes in the analysis of MEs (31,32). These studies stated that lack of experience was the most prevalent which was reported by 52% (31) and 39.2% (32) of participants.
Poor communication is an important cause of MEs in health care systems (18). In this study, 14% of junior and senior physicians attributed their MEs to faulty communication. In fact, routine team checklist briefings could have a positive effect on team communication and teamwork and therefore reducing ME.
Disclosure of MEs
Instead of concealing MEs, honest and transparent disclosure is emerging as the most appropriate way to deal with them (33). Disclosure concerned 87.7% of respondents in this study. More than half of respondents talked to peers after a severe ME. This datum confirms previous findings (33,34) suggesting that most physicians think they should share the story with a trusted colleague. Disclosing ME to patients is a challenging communication task. However, most physicians have never been trained in what to say, and how to say it (35). In the present study, disclosing ME to patients was reported by 10.1% of physicians. This finding is consistent with reports suggesting that physicians are reluctant to tell patients about MEs because disclosure to patients requires a specific set of communication skills frequently lacking in physicians’ training (36). This result is in line with that of some related studies (18,37). Legal and ethical experts, however, suggest that patients should generally be told about MEs (38). Hilfiker (39) argues that disclosing a ME to the patient may be the only way for the physician to achieve a sense of absolution. Majority of respondents who disclosed MEs were generally satisfied which is in line with a finding of a study concluding that many physicians sought solace by discussing an error (40).
Multiple barriers may inhibit physicians from disclosure such as blame, legal action, loss of self-confidence, and reputation damage (41). Thirty four percent of responders were dissatisfied after disclosing MEs in the present study and the main reasons were shame (72.2%), legal action (10.3%), and worry about blame (17.5%). The same results were reported by Wu et al. (42) who noted that disclosing MEs exposed physicians to the risk of malpractice suits and public reputation damage.
Impact of MEs
Physicians may suffer from severe distress, anxiety, guilt, shame, self-doubt, loss of self-esteem which may harm the quality of their professional and private life (43,44). These emotions can lead to a permanent emotional scar and a disruption in the therapeutic relationship with patients (45). As stated below, the high proportion of responders reporting no errors may refer to an underlying severe psychological impact, meaning they never coped with their errors. The overall median IES-R score for our respondents was 19. However, measuring the IES-R score retrospectively may underestimate it. In fact, Van Gerven et al. (46) noticed a decrease from 17.72 at time of the incident to 8.99 at the time of the questionnaire. The present study, along with other previous reports in literature, confirmed that individual characteristics influence the impact and that females tend to report significantly more distress than males. Those results are in line with previous reports (9,18,47–49,46). Seys et al. (47) explained the aforementioned finding by the fact that female “second victims” are more concerned about losing their confidence and being blamed, and experience more loss of reputation from their colleagues.
The degree of harm also influenced the impact of ME in the present study. These findings are in line with those of Van Gerven et al. (46) who mentioned that physicians experience the most severe impact after a serious harm incident. There is however a disagreement in the literature as to whether the impact on “second victims” depends on the severity of the event (48,50) or remains the same no matter what happened (51).
The “second victim” can live constant emotional distress and can develop PTSD (44,52,53). PTSD is a psychological disorder that could result from stressful events happening during the daily practice of physicians. Its symptoms may include insomnia, nightmares, reliving the incident repeatedly, loss of trust by their colleagues, lack of self-confidence, and fear of making another error (44,54). The current study examined the consequences of MEs on physicians. The data in the literature are extremely divergent concerning the prevalence of psychiatric disorders occurring after a traumatic event, which depends on the measuring instruments used as well as the events experienced (55–57). On the one hand, our frequency of PTSD (23.5%) was comparable with reports from previous hospital studies (eg; 17% of Germanium psychiatric hospital staff (56), 18.4% (55)). On the other hand, no cases were found in a Sweden study (57). Two significant risk factors for PTSD symptoms were identified in this study, namely female sex and high level of harm. The fact that females react more strongly is reported in other studies (46,47). Patel et al. (58) reported that work overload was the main contributor to ME. Residency was reported in literature as another risk factor. In fact, Bari et al. (59) reported that residents are a vulnerable population because residency is a learning period, and Abd Elwahab et al. (26) made it clear that junior physicians and residents are more prone to make MEs.
Few studies have investigated physicians’ needs and experiences in coping with the experience of error (18,60). Coping strategies used by “second victims” have a key role in how physicians involved in MEs will behave with their colleagues and subsequent patients. There are several different strategies for coping with the emotional impact after experiencing a ME. In this study, physicians used the following three coping strategies: problem-focused strategy, emotion-focused strategy, and seeking social support. These strategies are important for “second victims” to individually achieve an effective coping strategy through dealing with the ME, analyzing it, and learning from it, either alone or with colleagues. This finding was quasi in line with literature reporting that the two major used forms of coping are problem-focused coping and emotion-focused strategies (13,60,61). In problem-focused coping, physicians try to cope with the problem that causes distress and try to solve it (13). It aims to face up the mistake and address the problem directly. This finding was in line with the study of Harrison et al. (48) who reported that the most frequently and best coping method used was problem-focused strategy. In the emotion-focused strategy, physicians cope by managing the emotional distress caused by errors (62). In seeking social support, individuals talk with family and friends in order to find emotional comfort. It is the less frequent coping strategy in this study, which is in line with a study reporting that talking about MEs to family and friends is less common (63). The dynamic relationship between the emotional impact and the coping strategy after an error is challenging to capture. The emotional response to making a mistake may lead to the selection of a particular coping strategy that, in return, may elicit a further emotional response (64).
Changes in practice
Experiencing a ME can cause considerable changes in medical practice (60). These changes can be defensive or constructive (47). The findings in this study reveal that physicians considered that MEs more frequently lead to constructive changes. Communication and interaction with peers and superiors are perceived as the most helpful resources by 64.9% and 71.6% of participants, respectively. A minority of respondents (5%) reported defensive changes by keeping the ME to oneself and avoiding similar patients. Mizrahi et al. (65) described in a study conducted with internists in training, three defensive mechanisms to manage medical mistakes: denial process, discounting, and distancing.
This study has three limitations. First, over or under reporting cannot be entirely ruled out as a result of using of self-report questionnaires. It is true that in-depth interviews are more suitable for learning about MEs and their emotional impact; however, they could not be used because of the anonymous nature of the study. Second, this study included only physicians. It may be comprehensive to include other hospital employees (eg; nurses, midwives, pharmacists...) because they could be all concerned by MEs, and may be affected by stressful patient-related events. Finally, a ME is an annoying irony. This resulted in some people refusing to answer the questionnaire. In fact, the proportion of refusals could correspond to the most affected physicians.