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Getting emotional about mistakes in care

When patient safety is compromised, clinicians often react with guilt, frustration, embarrassment and sometimes anger. Even when the incident is minor, or when the patient wasn't harmed at all, it's common for people's emotions to get involved and for them to sometimes have trouble coping, a new study has found.

The research was carried out in Canada and appears in the latest issue of the Journal of the American Board of Family Medicine.

Although there's increasing recognition that caregivers often become the "second victims" after a patient is harmed, few studies have attempted to systematically examine how they feel and how they respond, especially in the medical office setting. Using a confidential questionnaire attached to incident reporting forms for a regional community practice medical safety program, the Canadian researchers collected data from physicians, nurses, managers and office staff at 19 family medicine practices in Alberta.

Here's what they found:

- Across the board, frustration was the most common emotional response to a patient safety incident. It was reported by 48.3 percent of the respondents. About one in three also reported feeling embarrassed, 12 percent said they were angry and 10 percent felt guilty.

- Whether the safety incident was minor or serious didn't seem to matter. Most caregivers and office staff reported some kind of emotional reaction when something went wrong or when there was a close call.

- The emotional impact was greater when the patient was harmed or when there was a possibility the harm was more than temporary.

- About 63 percent of the respondents reported using a coping strategy to deal with their feelings after an incident. Their most frequent response was to talk to someone else about it. But more than one out of three said they did nothing, and only 17 percent said they told the patient.

- Of note, the physicians in this study were more likely than the rest of the clinic staff to have an emotional reaction to an incident, and were also less likely to use a coping strategy in the aftermath.

Although this was a small study, one of its strengths is that it was based on real-life incidents and how people responded to them, rather than asking for their response to a hypothetical situation. It also captured the smaller-scale mistakes and miscues that can happen in daily office practice - losing or misfiling a patient's lab report, for instance - where most patients receive the majority of ongoing care.

Most of the patient safety incidents involved in this study were in fact relatively minor, which might account for why frustration, rather than guilt or blame, was the dominant emotional reaction. Other studies have found that anxiety, shame, self-doubt and self-blame are often part of the doctor's response to a medical mistake - but these studies generally focused on how doctors felt about the worst or most memorable mistakes of their career, rather than the daily ups and downs of primary care.

It's a side of office medicine that most patients don't see. Many might not even realize it exists. But whether patients are aware of it or not, it has an impact on care, the study's authors wrote.

When clinic employees, and doctors in particular, don't have good coping strategies for dealing with mistakes, they're at greater risk of burnout and depression, the authors wrote. it also can become a missed opportunity for personal and organizational learning.

"All members of the health care team report experiencing emotions related to patient safety incidents in their practice," the researchers wrote. "Incidents with minor or no harm still invoked emotional responses from the providers. It is important to understand the impact that patient safety incidents have on the medical clinic as a whole."