Patient Safety: Lessons Learned - The Second Victims

By Steven Chinn, DPM, MS, MBA, Administrative Director, Accreditation & Regulatory Affairs

In the past, whenever an adverse patient care event occurs, we have focused on taking care of the patient and secondarily, the patient's loved ones. Social services, spiritual services, nursing services and others are often called in to provide support and comfort to those involved. Patients and their families expect us to demonstrate compassion and caring. But what about the team that was involved in taking care of the patient? How do they respond? How do they cope?

Complications, clinical disasters, medical mistakes and death are part of being a health care professional. Many of us were taught that you win a few, lose a few, and sometimes it comes out a tie. I want to share two stories of health care professionals who faced losing a patient, and the toll that can take.

Early in my career, I was asked to lead an RCA on a patient who committed suicide after being discharged. A couple days after the event, the treatment team met to debrief over why this had occurred. They did an excellent job identifying system and process improvements necessary to prevent this from happening again. Right after the meeting, the social worker on the case who had been in the field for a little over a year, approached me and told me that she was done. She turned in her ID badge and keys, went to her office, gathered her belongings and left the building. Human Resources attempted to contact her, but learned she withdrew her license and left the profession.

More recently, a surgeon who had practiced for 20 plus years, operated on a patient who had a postoperative infection, developed sepsis and died, despite the team's best efforts to save the patient. The family reacted adversely to what was perceived as a "normal" elective surgical case. The surgeon tried his very best, involved other specialties to consult and had the support of the hospital to try to work with the family. Several months afterwards, he too called it a career, even though he could have practiced for at least another 10 years.

What is common between these two scenarios? Both of these individuals were highly trained, with a fair amount of experience. Both were involved in an adverse patient event. And both were ultimately traumatized to the point of leaving the health care profession. Health care professionals can be just as much of a victim as the patient.

As a result of cases such as these, Stanford University Medical Center through the Risk Authority is initiating a program to support physicians involved with adverse patient care events. The Peer Support Program, led by Dana Welle, DO, chief medical officer, the Risk Authority, has been developed in collaboration with the Stanford Committee for Professional Satisfaction and Support (SCPPS). The program trains physician peers who are able to assist or provide information to those who might have been involved in an adverse patient event. The work they do is completely voluntary, and both the physician peer supporters and the peer support team have developed this program to assist their colleagues through adverse events.

When a physician is involved in an unanticipated patient care outcome, he or she will be contacted by a member of the peer support team and offered confidential support. This is not intended to be psychiatric support, but rather peer support. Literature shows physicians respond more favorably to help from a colleague. Many physicians report a positive outlook from just the initial contact. For more information, contact Dr. Welle at dwelle@theriskauthority.com.