Peer Support: Mitigating the Emotional Toll of Medical Errors · 2016-05-13 · Title: Staff Support During Stressful Times Author: Information Systems Created Date: 5/13/2016 8:45:20

Copyright © 2016 by The Brigham and Women’s Hospital, Inc. All rights reserved.

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


Disclosures

No disclosures/conflicts


Thank you

The Institute for Healthcare Improvement

Hamad Medical Corporation


Team Sport Allison Lilly and Henri Menco: EAP

BWH Risk Management BWH

CMO

Patient Safety

Rick van Pelt,

Linda Kenney

CRICO: Beth Cushing,

Bob Hanscom

CPPS Staff

Tom Gallagher,

Albert Wu


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)


“where the human heart either gets welcomed or thwarted or broken.”

Parker Palmer. Quoted in Living the Questions, Jossey-Bass, San Francisco, CA,2005.

Institutions are…


The Center's mission is to encourage a culture that values and promotes

mutual respect, trust and teamwork.


Center for Professionalism

and Peer Support

Professionalism

Initiative

Teamwork

Training

Communication

Peer Support

Disclosure

Coaching

Defenda

nt Support

Wellness


Reflection

Think of a time when you were involved in a medical

error that caused patient harm.


What were some of your feelings?



Emotional impact of errors on clinicians

• Sadness

• Shame

– Self-doubt

• Fear

• Anger

• Isolation


“…[both stress] the need for perfection and a deep perception of personal

invulnerability…”

Helmreich’s observations: Similarity between medicine and aviation

Helmreich, Davies. Culture, Threat and Error: Lessons From

Aviation. Can J Anesth 2004; 51:6



• Sadness

• Shame

• Fear

• Anger

• Isolation


The Fantasy

“That’s OK Doc. I know you always try your hardest and that you were only trying to help me.”


More fantasy

No shame and blame

Shared responsibility

16


Vs. the Reality

Patient anger

Family anger

Litigation

Lack of support



• Sadness

• Shame

• Fear

• Anger

• Isolation



Many people may be significantly impacted

• Patient

• Family

• Physician

• Team

• Institution

Everyone should have access to support


Normal reactions to abnormal events

21


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


But sometimes recovery is thwarted…

23

… causing harm to clinicians and their patients

Many times reactions are transient



3,171 MDs surveyed in US and Canada

Waterman et al. Jt Comm J Qual Patient Saf. 2007 Aug;33(8).

Error impact


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. 2015 Mar;11(1):28-35.


Factors associated with perceived medical errors

Shanafelt et al, Annals of Surgery, 2010

27


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 5. 2002.


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

2010; 251(6)


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 2005

31


So, how do we facilitate coping and resilience after adverse events?

Disclosure

and apology

Learning from the error/

understanding how to

prevent recurrences

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. 2015 Sep 4.

Talking about it

with colleagues

Forgiveness

Dealing with

imperfection

Sharing that learning with

colleagues and trainees


BWH Peer Support Program

Sometimes an entire

team is affected

Group peer support


But physicians and clinicians at the sharp end of the error may

have different needs…


Attitudes and needs of physicians for emotional support:

The case for peer support

35

Hu J, Fix M, Hevelone N, Lipsitz S, Greenberg C, Weissman J,

Shapiro J. Arch Surg 2012


Barriers to seeking support

• Lack of time (89%)

• Stigma (77%)

• Lack of confidentiality (79%)

• Access (67%)


Sources of support

88

48

29

0

20

40

60

80

100

Physician Colleagues Mental Health Professionals

EAP

37

Perc

en

t

(%)

%

%

%


BWH Peer Support Program

Sometimes an entire

team is affected

Group peer support We also offer 1:1 peer

support


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


2 7 22 16 14

20

50 48

36

81

0

20

40

60

80

100

120

2012 2013 2014 2015

1:1 peer

support

1:1

defendantsupport

Peer and defendant support at BWH 2012 –2015 (n = 296)


Disclosure Impact

Do we think that any of these emotions might have an effect on our discussions with patients and

families?


Do we think that any of these emotions might have an effect on our discussions with patients and

families?

How could they not?

Disclosure Impact


Disclosure Coaching

Disclosure is a process, not an event


44

Safety culture impact


Naming adverse events leads to outcome bias and reinforces

unhelpful cultural biases

Errors

Incidents

Complications

Mistakes

Calamities

Negligence

Malpractice


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


Every safety and quality committee reinforces the culture

regarding how we respond to adverse events


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


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

system


Just Culture Reckless Behavior

Conscious Disregard of

Substantial and Unjustifiable Risk

Manage through:

• Remedial action • Disciplinary action

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

Product of Our Current System Design and Behavioral Choices

Manage by changing:

• Choices • Processes • Procedures • Training • Design • Environment

Console Coach Discipline

Consistency in Rules and

Response

Balanced Accountability

Human Error


Investigatory process


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



Several models of peer support programs

• Hospital

• Academic Medical Center

• Consortium of practice sites

• Insurers


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


Shoulders


Not victims

“we are not victims of that world, we are its co-

creators.

…source of awesome responsibility…and

profound hope for change.”

Palmer, P. Let Your Life Speak, Jossey-Bass,

San Francisco, CA, 2001.


Thank you for your engagement and commitment


References

• Charles SC, Wilbert JR, Franke KJ. Sued and nonsued physicians' self-reported reactions to malpractice litigation.

Am J Psychiatry. 1985 Apr;142(4):437-40.

• Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J

Gen Intern Med. 1992 Jul-Aug;7(4):424-31.

• Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician satisfaction and burnout at different

career stages. Mayo Clin Proc. 2013 Dec;88(12):1358-67.

• 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. 2014 Mar;89(3):443-51.

• 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; 50-542.

• Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: The tools

to achieve high reliability. Health Serv Res. 2006 Aug;41(4 Pt 2):1690-709.


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. 2015 Mar;11(1):28-35.

• 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. 2012 Mar;147(3):212-7.

• Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice risk according to physician specialty. N Engl J Med

2011; 365:629-636.

• 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):40-46.

• Martin CA, Wilson JF, Fiebelman ND 3rd, Gurley DN, Miller TW. Physicians' psychologic reactions to malpractice

litigation. South Med J. 1991 Nov;84(11):1300-4.


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). 2004 Jul-Aug;23(4):42-53.

• 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. 1990 Aug;76(2):245-50.

• Schernhammer E.Taking their own lives -- the high rate of physician suicide. N Engl J Med. 2005 Jun

16;352(24):2473-6.

• Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg.

2010 Jun;251(6):995-1000.

• Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine

residency program. Ann Intern Med. 2002 Mar 5;136(5):358-67.

• Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003 Apr 15;114(6):513-9.


References

• Shanafelt TD. Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-

centered care. JAMA. 2009;302(12):1338-40.

• 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. 2010 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. 2005 Jun 1;293(21):2609-17.

• Van Pelt F. Peer Support: Healthcare professionals supporting each other after adverse medical events. Quality and

Safety in Healthcare 2008; 17: 249-252.

• 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):467-76.

• Wu G, Feder A, Cohen H, Kim JJ, Calderon S, Charney DS, Mathé AA. Understanding resilience. Front Behav

Neurosci. 2013 Feb 15;7:10.

Documents

Peer Support: Mitigating the Emotional Toll of Medical Errors · 2016-05-13 · Title: Staff Support During Stressful Times Author: Information Systems Created Date: 5/13/2016 8:45:20