Even experienced, well-intentioned clinicians can falter in their work. But how to deal with unanticipated medical events remains an open question


In an ideal world, patients entering a hospital would benefit from the healing touch of doctors, nurses, other healthcare professionals, etc. and would emerge in a much better condition than before. While this indeed happens in a majority of cases, a disconcerting number suffer significant harm or even die on account of mistakes of healthcare staff at all levels.

According to one estimate published by the US Institute of Medicine, some 98,000 people in that country died each year because of serious blunders committed by the doctors and other staff. “That figure holds good even now,” says Dr K Sankaranarayanan, an international surveyor with the Joint Commission International (JCI), the global arm of US health regulator JCAHO (Joint Commission for Accreditation of Healthcare Organisations). It can easily be imagined that the number of US patients who suffered grievous injury because of iatrogenic causes could be much higher.

Dr Giridhar Gyani, the founder of NABH (National Accreditation Board for Hospitals) and the Director General of Association of Healthcare Providers of India (AHPI), says the total number of people in India who suffer annually on account of adverse medical occurrence could be as high as 5.2 million! This includes all manner of events, such as wrong medication, patient falls, hospital-acquired infections etc, he adds.


Difficult to cover up

For the longest time in the past, the entire hospital ecosystem would close ranks and somehow try to conceal the event and protect the healthcare professional from the blame. However, in recent years, with a growing emphasis on accreditation and the quality of healthcare services and regulatory requirements for reporting mishaps, institutional cover-ups have become increasingly difficult. What is happening instead is that a particular member of the staff is singled out for the blame, with very little support from the management. In international literature on hospital administration, this member of the healthcare staff is described as the Second Victim (the first being the patient who sustains the injury caused by the mistake).

Discussing the topic at a conference of the Consortium of Accredited Healthcare Organisations (CAHO) held in Mumbai recently, Dr Sankaranarayanan explained that the Second Victims involved in a “sentinel event” with regard to patient safety had to be handled with extreme care. Sentinel events are major events that have to be reported compulsorily to the top management for appraisal of quality-related performance of the institution.

“The episode is usually followed by a severe stress response if the error is serious and has resulted in death or grievous injury to the patient concerned,” Dr Sankaranarayanan said, adding that the health worker’s response comes in several stages: First, there is denial or distancing (oneself from the event), followed by a state of shock when the blame cannot be avoided and finally, a long-term response which can be self-doubt, a loss of confidence or a shift to a less critical job. Often, this could mean that a highly trained human resource such a heart surgeon could switch to being a family physician.

The phenomenon would not have grabbed so much attention of the top management of major hospitals if it were a rare occurrence, affecting only a small number of healthcare professionals. But Lt Colonel (Dr) Madhav Madhusudan Singh, secretary of the RFHHA (Research Foundation for Hospital and Healthcare Administration) quotes one survey which says that one in every seven healthcare professionals (175/1160) becomes a Second Victim sometime during their career. “I have been conducting a study on this subject over the past three years, in which I have interviewed approximately 300 Indian clinicians on this subject, and as many as 145 of them admitted that they had gone through such an experience,” Lt Col. Singh says.


Manifold trauma

He also reported that about 20 percent of his subjects could not sleep for about 7-10 days after each episode of severe medical errors, particularly because most of the affected clinicians were relatively young and inexperienced. When questioned further as to the cause of the medical error, almost 70 percent blamed themselves (and were filled with shame and self-doubt), while the remaining 30 percent held their organizations responsible for the overload of work. Investigations of unanticipated clinical events often reveal that experienced and well-intentioned clinicians can falter because of complex clinical conditions, poorly designed processes and inadequate communication patterns, he added.

According to a March 2018 article in the Indian Journal of Surgical Oncology, the trauma of the Second Victim is compounded or worsened manifold by the allegations of medical negligence and the legal proceedings that follow in state medical councils or in the courts. “Hence, the formulation of an awareness campaign will promote an open dialogue about the prevalence of Second Victims among our fellow professionals,” the article says. Besides, the development of surveillance, support strategies and the setting up of help-desks at various healthcare facilities would further help to mitigate the situation.

In a separate interview with Future Medicine, Dr Sankaranarayanan also emphasized that the hospital management were expected to offer a nuanced response, depending upon the nature and severity of the mistake made by the employee concerned. Thus, a single mistake, which appeared to be a genuine accident, could be dealt with through counseling and retraining by peers rather than superiors. However, a serious error, provoked by exhaustion or any other physical factors, could be avoided in the future by suitable corrective action. On the other hand, defiance on the part of the employee, or a refusal to bring about the required improvements despite adequate opportunities, should surely attract punishment.


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