Have you ever made a mistake while practicing medicine that negatively affected somebody’s life? Even if you haven’t yet, you probably will if you practice long enough. Have you thought of how you will recover afterwards? Fatal errors can affect healthcare providers all through their career.1 Self-forgiveness after a medical error facilitates open mindedness, recovery from trauma, relief of mental and emotional anguish, re-engagement, growth, and regained appreciation for life.2

It is prudent for healthcare professionals to learn and practice the skill of self-forgiveness to allow for recovery from the trauma of medical errors, which are likely to occur as they care for patients.

Medical errors are inevitable, but how one traverses the events that follow can compound mental anguish.1,3 In a heavily publicized case, 50-year-old Kim Hiatt, a seasoned nurse working in a neonatal intensive care unit at Seattle Children’s Hospital, injected 1,400 mg of calcium chloride into to a critically ill 8-month-old (a 10-fold dosing error) in September 2010.4 As a result, the infant died 5 days later. Ms. Hiatt was heavily sanctioned by the state nursing association and fired by her employer despite her appropriate response—immediately revealing the mistake and logging the error into the electronic medical record. Public investigative records revealed that it was her first known medical error.

Unfortunately, Ms. Hiatt committed suicide 7 months after the event.

The Journal of the American Medical Association reported the results of a focus-group study in 2003 that physicians “experienced powerful emotions following a medical error [and] felt upset and guilty about harming the patient…the most difficult challenge was forgiving themselves for the error.”5

Ms. Hiatt’s coping skills were likely diminished for many reasons after the death of her patient.4 Her colleagues and employer failed to support her after her mistake. Without their support, she struggled and ultimately was unable to navigate the fallout of the trauma. With institutional support, she might have negotiated the aftermath without becoming another victim. Self-forgiveness is an important step in order to move past these unfortunate events.2

The authors of an article published in Academic Medicine asked 61 doctors, “What helps physicians after committing a serious medical error?”2 One physician commented that “doctors have long been thought of as perfect.” However, perfection is clearly an unattainable standard. Because of this phenomenon, healthcare institutions are recognizing increasingly that providers are at risk of becoming “second victims” when medical errors occur, as in the case of Kim Hiatt.4,6,7 And being a second victim is often exacerbated by a sense of responsibility for the patient’s outcome, which is often faced alone and without institutional support.

While we can’t go back and undo the errors, our response can allow opportunity for personal growth, assimilation back into the medical team, accountability to the patient’s family, and instructive lessons for colleagues on how to avoid similar errors.3,5 With the death of Ms. Hiatt came the loss of 25 years of nursing experience that could have continued to prove valuable in the care of many subsequent patients.

SCOPE OF THE ISSUE

A medical error is formally defined as a “preventable adverse effect of medical care, whether or not it is evident or harmful to the patient.”6 Medical errors are responsible for an alarming 250,000 estimated deaths in the U.S. annually. Only heart disease and cancer kill more Americans.8,9 The number of deaths attributed to medical errors is also very likely to be underreported for many reasons, and the total deaths related to medical errors have been estimated to be as high as 440,000 per year.10

According to the Agency for Healthcare Research and Quality, the eight most common medical errors involve communication problems, inadequate information flow, patient identification and assessment, human error, organizational transfer of knowledge, staffing patterns and workflow, inadequate policies, and technical failures.11 And while most of us enter medicine with noble intentions and unbridled idealism, the inescapability of medical errors quickly becomes undeniable. Many providers, in their quest for perfection in clinical practice, understandably develop loneliness, depression, substance abuse, and shame.12,13 Providers are taught to “suck it up” and “show no cracks.” So, the natural question becomes: How can providers navigate the negative emotions resulting from medical errors in such an unforgiving environment?

HOW TO HEAL AFTER THE ERROR

Clinical psychologists suggest that the ability to forgive is one characteristic of an emotionally healthy person.5 However, self-forgiveness can be a process that takes significant time and effort. Self-forgiveness is necessary, though, because it enables medical providers to continue to practice effectively after errors.

Let’s, therefore, examine how self-forgiveness works.

Elements shared across the various models of forgiveness for others include choosing to forgive, committing to forgiveness, recalling the hurt and evaluating the feelings, dealing with the anger, seeking empathy toward the transgressor, and reflecting on how unforgiveness is affecting the victim’s wellbeing.14

We commonly are harder on ourselves than on others. But self-forgiveness is not about letting yourself off the hook. It is about accepting what has happened and finding the will to move past it. Self-forgiveness, therefore, requires self-acceptance and self-awareness. Various authors have proposed a four-stage therapeutic approach for self-forgiveness involving:15,16

  1. Responsibility
  2. Remorse
  3. Restoration
  4. Renewal

Responsibility

Taking responsibility for an error demonstrates compassion for the patient harmed by the error and fosters rebuilding trust for the patient and their family. This is about accepting the mistake and moving past it. Taking responsibility is often the hardest step. It means we stop making excuses, rationalizing, and justifying what we did. It is the time when we face the error. Taking responsibility often can reduce the negative emotions after an error such as regret, shame, and guilt.

Remorse

After taking responsibility, showing remorse is the next step toward healing. Remorse can be a painful emotion that arises from regret of a past event. Without it, internal resolution and self-forgiveness will likely be difficult. By expressing remorse when one has erred, these feelings can become a springboard toward positive change.

Remorse is often tied together with guilt and shame, which commonly arise in the fallout after an error. To achieve self-forgiveness, it helps to sit with guilt and avoid shame. The difference between the two is subtle, but important. Guilt implies that the mistake was a bad action, whereas shame suggests that the mistake signifies the whole person is bad. Shame tends to be more pervasive and can lead to substance abuse and depression. Additionally, holding onto shame damages self-esteem and can, therefore, be counterproductive to doing self-work toward positive change.

Restoration

Restoration is an action step that follows responsibility and remorse. In this step, we must act sincerely to make amends and work to repair any damage. While it is natural to try to downplay the event or ruminate on how others might have been the cause, these thoughts do not move you forward.

Restoration involves adherence to a code of medical ethics—and to a sense of fairness and what’s right. After medical harm occurs, sound ethical practice demands disclosure of the error to patients and their families, apology, and fair compensation for damages. These are actions that help providers rectify their mistakes and restore trust.

Renewal

Negative emotions and self-judgment are expected after an adverse medical event. In the renewal phase, these negative emotions are released to allow for healing. In releasing the negative emotions, we are not forgetting. Rather, we are appreciating our intrinsic worth, stopping self-punishment, and embracing self-compassion, acceptance, and respect.

Renewal offers an opportunity to renew commitment to our values, as well. Providers are held to high standards and living up to them can be difficult. Accepting our limitations and weaknesses can provide an opportunity to approach our work with a renewed and more realistic set of expectations for our performance.

BRINGING IT ALL TOGETHER

Recovering from a medical mistake may take years.2 Self-forgiveness is an important skill for healthcare providers to develop because we will all make an error at some point in our careers.1 Society simply cannot bear to lose a provider every time a medical error is committed.

What if Ms. Hiatt had been able to forgive herself? Her 25 years of nursing expertise might have been salvaged, offering an opportunity to positively affect many more lives.

Care organizations and medical licensing boards must begin to accept some responsibility for their contribution to the current environment and the second victim syndrome. In the meantime, the one thing we as providers can control is our willingness to practice self-forgiveness, which is crucial for getting through the negative emotions that occur after a medical error.

Self-forgiveness is one step in the process of how we learn, heal, and move forward. Genuine self-forgiveness is not shallow grace. It is about making changes, getting past the event, and learning from it. By granting ourselves forgiveness, we can learn to accept what has happened and move on.

Bad things happen, but tragedy offers opportunity for positive change. After medical errors, we, as providers, can find ways to make some good come from them. Self-forgiveness is the critical first step in our response to medical errors and necessary in creating space for healing and growth.

REFERENCES

  1. Kohn L, Corrigan J, Donaldson M. To err is human: Building a safer health system. National Academy Press. 2000. Available at: https://www.nap.edu/read/9728/chapter/1. Accessed October 11, 2020.
  2. Plews-Ogan M, May N, Owens J, et al. Wisdom in medicine: what helps physicians after a medical error? Acad Med. 2016;91(2):233–241.
  3. Petronio S. Impact of medical mistakes: navigating work–family boundaries for physicians and their families. Communication Monographs. 2006;73(4):462-467.
  4. Saavedra SM. Remembering Kim Hiatt: casualty of second victim syndrome. Nurse Labs. 2019. Available at: https://nurseslabs.com/remembering-kimberly-hiatt-casualty-second-victim-syndrome/. Accessed July 27, 2020.
  5. Berlinger N. Resolving harmful medical mistakes-is there a role for forgiveness? AMA J Ethics. 2011;13:647-654.
  6. Agency for Healthcare Research and Quality. Second victims: support for clinicians involved in errors and adverse events. PSNet. Available at: http://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events. Accessed October 13, 2020.
  7. Ozeke O, Ozeke V, Coskun O, Budakoglu II. Second victims in health care: current perspectives. Adv Med Educ Pract. 2019;10:593-603.
  8. Gallagher TH, Waterman AD, Ebers AG, et al. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-1007.
  9. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ.2016 May 3;353:i2139.
  10. Carver N, Gupta V, Hipskind JE. Medical error. StatPearls. Available at: http://www.ncbi.nlm.nih.gov/books/NBK430763/. Accessed Oct 12, 2020.
  11. Agency for Healthcare Research and Quality. AHRQ’s patient safety initiative: building foundations, reducing risk. AHRQ. 2003. Available at: https://archive.ahrq.gov/research/findings/final-reports/pscongrpt/psini2.htm. Accessed November 6, 2020.
  12. Baldisseri MR. Impaired healthcare professional. Crit Care Med. 2007;35(2 Suppl):106.
  13. Gold KJ, Schwenk TL. Physician suicide—a personal and community tragedy. JAMA Psychiatry. 2020;77(6):559-560.
  14. Norman K. Forgiveness: how it manifests in our health, well-being, and longevity. Scholarly Commons PENN Libraries; 2017.
  15. Cherry K. How to forgive yourself. Verywell Mind. Available at: https://www.verywellmind.com/how-to-forgive-yourself-4583819. Accessed Oct 11, 2020.
  16. Cornish MA, Wade NG. A therapeutic model of self-forgiveness with intervention strategies for counselors. Journal of Counseling & Development. 2015;93(1):96-104.
Overcoming the Trauma of Making a Medical Error: Self-forgiveness is an Important Skill for Recovery
Author

Kathi Norman, MSBS, MAPP, DMSC, PA-C

Author

Kathi Norman, MSBS, MAPP, DMSC, PA-C

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