PS 105 Lesson 3.docx - PS 105 Lesson 3 The Impact of Adverse Events on Caregivers The Second Victim Caregivers Are Victims Too After miscalculating the

PS 105 Lesson 3.docx - PS 105 Lesson 3 The Impact of...

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PS 105 Lesson 3: The Impact of Adverse Events on Caregivers: The Second Victim Caregivers Are Victims, Too After miscalculating the medication dosage for a frail infant, Kim Hiatt, RN, struggled with both the death of her patient and the loss of a career she loved. Kim Hiatt had worked as a nurse for 24 years when she made her first medical error: She gave a frail infant 10 times the recommended dosage of a medication. “Miscalculated in my head the correct [dosage] according to the mg/ml,” she wrote in the patient’s record — right before being escorted from the hospital building and told to stay away and not call. Five days later, the baby died. Hiatt was fired. Seven months after her error, Hiatt killed herself. The details of Hiatt's story — the mistake she made, how she struggled with that tragedy, and how she failed to get the support she needed — were reported in Vox . 1 The sad truth is that the intense emotions she felt after her error were not far outside the normal range of what some caregivers experience. Although an adverse event can teach some caregivers to be more humble and skillful — and many health care providers adjust well to the demands of a traumatic clinical event — for others, the long-term effects can be devastating. A 2007 survey of more than 3000 physicians validated that, when involved in medical errors, emotional distress is prevalent, and organizational resources to support physicians after errors need improvement. 2 Remember Linda Kenney and Dr. Rick van Pelt, the anesthesiologist whose error caused her permanent harm? In the video they talk about the healing process after the error — for both of them: When an adverse event occurs, patients and families are the first victims we think about — and that makes sense. But they are not the only ones suffering during this time, especially if the adverse event results in serious patient harm. This lesson takes a closer look at the importance of supporting the caregivers involved in the incident, whom some refer to as "second victims."
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Attribution Error and Unfair Blame As discussed in this and other courses, system failures related to the complexity of health care are usually the predominant cause of adverse events. (Review PS 102: From Error to Harm to learn more.) But even so, it's easy to blame the people who are involved in errors. Here's how Dr. van Pelt described feeling after his medical error: 3 We learn and experience that while adverse events occur frequently, that they are unacceptable and a mark of failure ('first, do no harm'). We learn that to acknowledge responsibility in an adverse event is a set up for litigious retribution. We learn that seeking support from mental health professionals is a sign of weakness. In short, we create a culture that expects care providers to be lone super heroes and a health care system that supports this belief. I don’t think that I expected support from my colleagues or from my institution following my adverse medical event. The shame, the lack of confidence, the guilt and the vulnerability were mine to deal with in isolation. That’s the way the system was set up.
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  • Fall '18
  • mental health, medical error, Patient safety, Iatrogenesis, Dr. van Pelt, Linda Kenney

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