CASE A surgeon's story of patient loss
It was a Wednesday morning and Ms. M was my first case of the day. I knew her well, having delivered her 2 children. Now she had a 7-cm complex cyst on her right ovary, she was in pain, and she was possibly experiencing ovarian torsion. My resident took care of the paperwork, I met the patient in preop, answered her few questions, and reassured her husband that I would call him as soon as surgery was over. She was rolled to the operating room.
When I entered the OR, Ms. M was under general anesthesia, draped, and placed on the operating table in the usual position. I made a 5-mm incision at the umbilicus and inserted the trocar under direct visualization. There was blood and the camera became blurry. I removed the camera to clean it, and the anesthesiologist alerted me that there was sudden hypotension. I reinserted the camera and saw blood in the abdomen. I feared the worst—major vessel injury. I requested a scalpel and made a midline skin sub–umbilical incision, entered the peritoneal cavity, and observed blood everywhere. The massive transfusion protocol was activated and vascular surgery was called in. I could not find the source of the bleeding. Using a laparotomy towel I applied pressure on the aorta. The vascular surgeon arrived and pushed my resident away. He identified the source of the bleeding: The right common iliac artery was injured.
The patient coded, the anesthesiologist initiated CPR, bleeding continued, blood was being transfused, and after 20 long minutes of CPR the lifeless body of my patient could not hold any more. She was pronounced dead on the table.
At that moment, there were multiple victims: Ms. M lying on the surgical table; her family members, who did not know what was happening; and the surgical team members, who were looking at each other in denial and feeling that we had failed this patient, hoping that we would wake up from this nightmare.
Defining patient harm
Many patients experience harm each year because of an adverse medical event or preventable medical error.1 A 2013 report revealed that 210,000 to 440,000 deaths occur each year in the United States related to preventable patient harm.2 Although this fact is deeply disturbing, it is well known that modern health care is a high-risk industry.
Medical errors vary in terms of the degree of potential or actual damage. A “near miss” is any event that could have resulted in adverse consequences but did not (for example, an incorrect drug or dose ordered but not administered). On the other hand, an “adverse event” describes an error that resulted in some degree of patient harm or suffering.3
For each patient who dies because of a medical error or a surgical complication, whether preventable or not, many clinicians are involved in the unfolding of the case. These events have a profound impact on well-intentioned, competent, and caring physicians, and they elicit intense emotional responses.4 When a patient experiences an unexpected adverse surgical outcome, the surgeons involved in their care may become “second victims.” They may feel that they have failed the patient and they second-guess their surgical skills and knowledge base; some express concern about their reputation and perhaps career choice.
Psychological responses. It is importantto understand this process to ensure a healthy recovery. Psychological responses to an adverse medical event include guilt; distress, anxiety, and fear; frustration and anger; feelings of insufficiency; and long-standing suffering. Clinicians who experienced an adverse medical event have reported additional psychological as well as physical symptoms in the aftermath of the event (TABLE 1).5
Risk factors. Certain factors are associated with a greater emotional impact of an adverse medical event, including6:
- severity of the harm or leaving permanent sequelae
- death of a healthy patient or a child (for example, from a motor vehicle accident)
- self-blame for the error
- unexpected patient death (for example, a catastrophic complication after a relatively benign procedure)
- physicians-in-training responsible for the patient
- first death under a clinician’s watch.
While most research in the field of medical error focuses on systems or process improvement, it is important not to neglect the individual and personal aspects of the clinicians involved in the event. The health care system must include care for our injured colleagues, the so-called second victims.