Peer Support: Mitigating the Emotional Toll of Medical Errors

Transcription

1 Peer Support: Mitigating the Emotional Toll of Medical Errors Jo Shapiro, MD, FACS Director, Center for Professionalism and Peer Support Brigham and Women s Hospital Associate Professor, Otolaryngology Harvard Medical School

2 Disclosures No disclosures/conflicts

3 Thank you The Institute for Healthcare Improvement Hamad Medical Corporation

4 Team Sport Allison Lilly and Henri Menco: EAP BWH Risk Management CMO BWH Patient Safety CRICO: Beth Cushing, Bob Hanscom CPPS Staff Tom Gallagher, Albert Wu Rick van Pelt, Linda Kenney

5 Brigham and Women s Hospital 793-bed tertiary care facility Major teaching hospital for Harvard Medical School Physician and scientist faculty: 2,738 (60% male, 40% female)

6 Institutions are where the human heart either gets welcomed or thwarted or broken. Parker Palmer. Quoted in Living the Questions, Jossey-Bass, San Francisco, CA,2005.

7 The Center's mission is to encourage a culture that values and promotes mutual respect, trust and teamwork.

8 Center for Professionalism and Peer Support Professiona lism Initiative Teamwork Training Communica tion Peer Support Disclosur e Coaching Defenda nt Support Wellness

9 Reflection Think of a time when you were involved in a medical error that caused patient harm.

10 What were some of your feelings?

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12 Emotional impact of errors on clinicians Sadness Shame Self-doubt Fear Anger Isolation

13 Helmreich s observations: Similarity between medicine and aviation [both stress] the need for perfection and a deep perception of personal invulnerability Helmreich, Davies. Culture, Threat and Error: Lessons From Aviation.

14 Emotional impact of errors on clinicians Sadness Shame Fear Anger Isolation

15 The Fantasy That s OK Doc. I know you always try your hardest and that you were only trying to help me.

16 More fantasy No shame and blame Shared responsibility 16

17 Vs. the Reality Patient anger Family anger Litigation Lack of support

18 Emotional impact of errors on clinicians Sadness Shame Fear Anger Isolation

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20 Many people may be significantly impacted Patient Family Physician Team Institution Everyone should have access to support

21 Normal reactions to abnormal events 21

22 Reactions may include Behavioral: insomnia, decreased productivity Emotional: anxiety, fear, anger, depression, loss of confidence Cognitive: impaired concentration, obsessive re-play of event Physical symptoms: fatigue, backaches, nausea 22

23 Many times reactions are transient But sometimes recovery is thwarted causing harm to clinicians and their patients 23

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25 Error impact 3,171 MDs surveyed in US and Canada Waterman et al. Jt Comm J Qual Patient Saf Aug;33(8).

26 Error impact 265 MDs and nurses in two large teaching hospitals in the UK and US Following medical error 30%: At least moderate negative impact on work performance or personal life Strained colleague relationships Harrison R, Lawton R, Perlo J, Gardner P, Armitage G, Shapiro J. J Patient Saf Mar;11(1):28-35.

27 Factors associated with perceived medical errors Shanafelt et al, Annals of Surgery,

28 Burnout Burnout is a syndrome of depersonalization, emotional exhaustion and a sense of low personal accomplishment that leads to decreased effectiveness at work. Shanafelt, TD, Bradley, KA et al. Annals. of Internal Medicine, Vol. 136, no

29 Burnout and medical error N = 7,905 participating surgeons Each one point increase in depersonalization = 11% increase in likelihood of reporting having made an error Each one point increase in emotional exhaustion = 5% increase Burnout and depression = independent predictors of reporting a recent major medical error Shanafelt TD, Balch CM, et al. Ann Surg

30 Physician suicide 40% HIGHER: The suicide rate among male doctors than among men in general 130% HIGHER: The suicide rate in female doctors than among women in general Schernhammer E. NEJM

31 So, how do we facilitate coping and resilience after adverse events? Talking about it with colleagues Dealing with imperfection Disclosure and apology Learning from the error/ understanding how to prevent recurrences Forgiveness Sharing that learning with colleagues and trainees Plews-Ogan M, May N, Owens J, Ardelt M, Shapiro J, Bell SK. Wisdom in medicine: What helps physicians after a medical error. Acad Med Sep 4.

32 BWH Peer Support Program Group peer support Sometimes an entire team is affected

33 But physicians and clinicians at the sharp end of the error may have different needs

34 Attitudes and needs of physicians for emotional support: The case for peer support Hu J, Fix M, Hevelone N, Lipsitz S, Greenberg C, Weissman J, Shapiro J. Arch Surg

35 Barriers to seeking support Lack of time (89%) Stigma (77%) Lack of confidentiality (79%) Access (67%)

36 Percent (%) Sources of support % % 29 % 0 Physician Colleagues Mental Health Professionals EAP 37

37 BWH Peer Support Program Group peer support We also offer 1:1 peer support Sometimes an entire team is affected

38 Training in peer support Listening: empathic, non-judgmental Sharing experiences Reinforce coping skills Encourage teaching and involvement in systems safety Resource information and referral 39

39 Peer and defendant support at BWH (n = 296) :1 peer support 1:1 defendant support

40 Disclosure Impact Do we think that any of these emotions might have an effect on our discussions with patients and families?

41 Disclosure Impact Do we think that any of these emotions might have an effect on our discussions with patients and families? How could they not?

42 Disclosure Coaching Disclosure is a process, not an event

43 Safety culture impact 44

44 Naming adverse events leads to outcome bias and reinforces unhelpful cultural biases Errors Negligence Incidents Malpractice Complications Mistakes Calamities

45 What we know but don t act on Human error is inevitable We work within systems that have fallibilities The systems were designed by humans and with limited resources Sometimes there are competing values

46 Every safety and quality committee reinforces the culture regarding how we respond to adverse events

47 Outcome Bias We tend to focus on the outcome instead of the choice made by the individual We cannot judge the quality of a person s choice by the outcome, good or bad We punish for mistakes where there is harm Drives error reporting down Focuses on the wrong part of the event

48 If we want to learn, we need to examine the choice and the system

49 Human Error Product of Our Current System Design and Behavioral Choices Manage by changing: Choices Processes Procedures Training Design Environment Just Culture At-Risk Behavior A Choice: Risk Believed Insignificant or Justified Manage through: Removing incentives for at-risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Reckless Behavior Conscious Disregard of Substantial and Unjustifiable Risk Manage through: Remedial action Disciplinary action Console Coach Discipline Balanced Accountability Consistency in Rules and Response

50 Investigatory process

51 When else do we offer peer support? Adverse events Colleague s illness Death of beloved patient Chronic stress Care of trauma victims Global crisis relief work

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53 Several models of peer support programs Hospital Academic Medical Center Consortium of practice sites Insurers

54 Peer support is so valuable because it combats: Culture of invulnerability human factors Shame and blame promotes Just Culture Expectation of emotional denial normalizes reactions Solely personal responsibility systems issues Isolation community/solidarity Self care is selfish it s important so that you can get back to doing what you do well Helps us focus on compassion for the patient

55 Shoulders

56 Not victims we are not victims of that world, we are its cocreators. source of awesome responsibility and profound hope for change. Palmer, P. Let Your Life Speak, Jossey-Bass, San Francisco, CA, 2001.

57 Thank you for your engagement and commitment

58 References Charles SC, Wilbert JR, Franke KJ. Sued and nonsued physicians' self-reported reactions to malpractice litigation. Am J Psychiatry Apr;142(4): Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med Jul-Aug;7(4): Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician satisfaction and burnout at different career stages. Mayo Clin Proc Dec;88(12): Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med Mar;89(3): Fix ML, Weissman JS, Park E, Hevelone N, Shapiro J. Attitudes and barriers to physicians receiving assistance for personal and professional struggles: A survey of emergency physicians, anesthesiologists, and surgeons. Ann Emerg Med 2007; Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: The tools to achieve high reliability. Health Serv Res Aug;41(4 Pt 2):

59 References Harrison R, Lawton R, Perlo J, Gardner P, Armitage G, Shapiro J. Emotion and coping in the aftermath of medical error: A cross country exploration. J Patient Saf Mar;11(1): Helmreich RL, Davies JM. Culture, threat and error: lessons from aviation. Can J Anesth 2004;51(6):R1 R4. Hu J, Fix M, Hevelone N, Lipsitz S, Greenberg C, Weissman J, Shapiro J. Attitudes and needs of physicians for emotional support: the case for peer support. Arch Surg Mar;147(3): Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice risk according to physician specialty. N Engl J Med 2011; 365: Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE. Reporting medical error to improve patient safety a survey of physicans in teaching hospitals. Arch Int Medicine. 2008; 168(1): Martin CA, Wilson JF, Fiebelman ND 3rd, Gurley DN, Miller TW. Physicians' psychologic reactions to malpractice litigation. South Med J Nov;84(11):

60 References Mello MM, Studdert DM, DesRoches CM, Peugh J, Zapert K, Brennan TA, Sage WM. Caring for patients in a malpractice crisis: physician satisfaction and quality of care. Health Aff (Millwood) Jul-Aug;23(4): Rosenblatt RA, Weitkamp G, Lloyd M, Schafer B, Winterscheid LC, Hart LG. Why do physicians stop practicing obstetrics? The impact of malpractice claims. Obstet Gynecol Aug;76(2): Schernhammer E.Taking their own lives -- the high rate of physician suicide. N Engl J Med Jun 16;352(24): Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg Jun;251(6): Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med Mar 5;136(5): Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med Apr 15;114(6):513-9.

61 References Shanafelt TD. Enhancing meaning in work: a prescription for preventing physician burnout and promoting patientcentered care. JAMA. 2009;302(12): Sirriyeh R, Lawton R, Gardner P, Armitage G. Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being. Qual Saf Health Care Dec;19(6):e43. Studdert DM1, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, Brennan TA. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA Jun 1;293(21): Van Pelt F. Peer Support: Healthcare professionals supporting each other after adverse medical events. Quality and Safety in Healthcare 2008; 17: Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007; 33(8): Wu G, Feder A, Cohen H, Kim JJ, Calderon S, Charney DS, Mathé AA. Understanding resilience. Front Behav Neurosci Feb 15;7:10.