Program helps caregivers under stress after errors

A tired physician prescribes the wrong medication. A surgeon misreads a patient's chart. A nurse inserts the wrong IV or administers too great a dose of a drug.

Even the best health care professionals may make mistakes, and some lapses can lead to illness, injury or death. But a growing body of research suggests it's not just the patients who are affected in such cases.


Caregivers often suffer emotional and physical harm in the wake of their medical errors, a surprisingly common problem that can reduce their effectiveness, compromise patient safety and lead to professional attrition.

Two local hospitals are starting a program to help them.

Greater Baltimore Medical Center recently introduced Caring for Caregivers, an initiative designed by the Maryland Patient Safety Center and Johns Hopkins Hospital's Armstrong Institute for Patient Safety and Quality. The University of Maryland Medical Center will launch a similar program next month.

In each, the facility chooses and assembles a team of about two dozen peer responders, volunteers trained to lend an ear to caregivers who are dealing with the aftermath of an error they've made or with some other clinically related stress.

The programs address a problem that Dr. Albert Wu, an internist and researcher in medical safety at the Johns Hopkins Bloomberg School of Public Health, first noticed about 20 years ago and has called the "second-victim" phenomenon.

The first victims of a medical error, he said, are patients and their families, but "the second set of victims, the health-care professionals involved in the incident, need help as well," he wrote in a 2002 article. "Their pain and devastation are no less real. Initially, they need emotional support and empathy. … The opportunity to explore the incident in safety is important … for constructive change."

And stress doesn't have to come from an error. Even trained professionals can suffer when a patient they know dies or receives an upsetting diagnosis, whatever the cause, said nurse practitioner Connie Noll, the clinical practice and education specialist for psychiatry at the University of Maryland Medical Center.

"In order to care about someone else, you have to leave a piece of yourself vulnerable. We are affected by what we see, and sometimes we need help with it," Noll said.


Medical errors are more widespread than the public might think. A 2000 study by the Institute of Medicine, "To Err Is Human," found that as many as 100,000 people die in U.S. health care facilities because of preventable mistakes every year.

A decade later, a study by the Department of Health and Human Services' Office of Inspector General found the number could be nearly twice that, and Wu said surveys have shown that virtually all medical caregivers can recall an incident in which they made a mistake that harmed a patient.

"Surveys have also suggested that between 10 percent and 50 percent of health care workers identify that they have been a 'second victim' of an adverse patient event," Wu wrote in an email from Uganda, where he was part of an Armstrong Institute team working with the World Health Organization.

If the numbers are surprising, experts say, it's partly because we tend to expect that health care providers, unlike all other human beings, should be perfect on the job.

Several factors have long strengthened that illusion. Medical professionals have little incentive to admit error, given the lawsuits and losses that could follow, and no legal protections existed for those who might wish to share their experiences.

That left caregivers deeply vulnerable.


Most "entered the profession to help people," said Carolyn Candiello, GBMC's vice president for quality and safety, a fact that can make it "truly devastating" for caregivers to deal with mistakes they've made that cause harm. The disincentive to open up only worsened matters.

Wu's research has shown that such professionals can suffer shock, guilt and anger in the short term and social isolation, symptoms of post-traumatic stress disorder, severe depression and even suicide in the long term.

Some end up leaving the profession — an expensive move, given that it can cost about $200,000 to replace physicians who leave the workforce and $60,000 per nurse, according to Robert Imhoff, president of Elkridge-based Maryland Patient Safety Center.

In the wake of the Institute of Medicine report, Congress passed the Patient Safety and Quality Improvement Act, a bill that authorized the Department of Health and Human Services to create dozens of "patient safety organizations," nongovernment entities that can collect and analyze data about "adverse" patient events while protecting the respondents' confidentiality.

Imhoff's organization is one such place. Working with hospitals and long-term care facilities across the state, it has tracked patient safety trends since 2004, offering resources to address the problems they uncover.

When Wu and a colleague, registered nurse Cheryl Connors, set up a pilot counseling program for "second victims" at Johns Hopkins Hospital in 2012, the safety center took notice.

The center offered Wu and Connors the financial backing to develop a similar initiative, but one that could be exported to community hospitals. GBMC became a customer, calling their program Caring for Caregivers, and the University of Maryland Medical Center soon followed, dubbing its program Resiliency in Stressful Events, or RISE.

Wu, Connors and a colleague visited each place, training volunteers from every aspect of the health care field — medicine, nursing, administration and more.

"All that's required is that you be in the profession and be an effective listener," said Michael Finegan, a GBMC administrator who has been a peer responder since April. "Our goal is to provide 'psychological first aid' — to be there, let people talk, and hear them out. If they need longer-term intervention, they'll go elsewhere for that."

At GBMC, 25 professionals spent eight hours each poring over case studies, watching relevant videos, brainstorming possible crises and acting out scenarios before becoming part of the team

"What I'm hearing is that we've already helped a few colleagues unburden themselves," said Finegan, who handled two calls during his first week.

Another 24 got similar training in the University of Maryland and are ready to begin work in July, said Noll, adding that she has gotten nothing but positive reactions from the staffers she has spoken to.

The field is still so new that it's hard to quantify results, said Imhoff, adding that both GBMC and the university center would be tracking the programs' progress.

But he's convinced such programs fit in with the larger mission of improving patient safety.

"Hospitals have always offered long-term counseling," he said. "This is an extension of that caring mentality. From what I'm hearing, employees are saying, 'This idea is great. My organization cares about me.' That's good for everyone."


An earlier version of this article misstated where Connie Noll worked and the name of the University of Maryland institution participating in the program. The Baltimore Sun regrets the error.