I’ve been a nurse for a long time, almost 27 years. During that time, I’ve taken care of thousands of patients and administered tens of thousands of medications. Mistakes happen, and I’ve made my share.

I remember the first mistake I made like it was yesterday. I was a new nurse working on a medical-surgical floor. My patient was ordered 0.125 milligrams of intravenous digoxin (a heart medication). I went to the medication drawer and pulled out an ampule of digoxin. I looked at it and the medication order, then I went to the patient bedside and looked at it again.

Right patient? Check. Right drug? Check. Right time? Check. Right route? Check. Right dose? Check. Except it wasn’t the right dose. I gave that patient 0.25 milligrams (twice the prescribed dose) of digoxin.

I knew I did it when I was throwing away the empty ampule. I don’t know how I missed it, but it sent me into a full-blown panic. My patient looked OK, but I had no idea what consequences she might face because of my error. I told the charge nurse what happened, and we called the physician. We continued to monitor the patient throughout the day and passed the information on to the night shift.

My patient was fine. I was not.

The charge nurse told me I needed to be more careful. And I was. I’m fairly certain I’ve never given anyone the wrong dose of digoxin again. But this wasn’t the last error I would make.

A few years later, I was taking care of an elderly gentleman in the last days of his life. We all knew his time was soon, but he was an optimist—and one of the kindest souls I have ever met. His daily lab work came back during my shift, and his phosphorus level was low. I called his physician, and she ordered 10 milliliters (just a little bit) of Fleet Phospho-Soda.

The pharmacy sent a 45-milliliter bottle—a normal dose for a colonoscopy prep—and I gave him the whole thing. I don’t know why. I can make excuses about being busy, being distracted, or being short-staffed, but I won’t.
My patient had a miserable night; he cried and said he was ready to die. I cried too. It was the last time I cared for him, because he did die two days later before my next scheduled shift. In my mind, I killed him. I killed his will to live. He deserved a better nurse and a better ending. I still think about him.

I remember what he looked like. I remember his laugh and his smile. I remember the misery I caused him.

They say time is a healer, and I guess I’ve made peace with my patient and myself. But experiences like these never really leave you. And for some, they cause more than just a painful memory.

Healthcare workers involved in serious errors may be impacted on a deeply personal level, sometimes experiencing depression, anxiety, or post-traumatic stress disorder.

The term “second victim” was first used by Dr. Albert Wu more than 20 years ago.¹ Two decades later we still haven’t come to terms with the impact medical error has on caregivers. Our concern often centers on the patient and their family, as it should. But as leaders and clinicians, we also have an obligation to our colleagues.

Just as no patient should be left to navigate these dark waters alone, neither should the clinician.

As a senior leader, it is your responsibility to make this a priority, dedicating time and resources to the work. But you don’t have to figure it all out on your own. There is already a framework developed and ready for implementation.

Care for the Caregiver is one part of the Communication and Optimal Resolution (CANDOR) process, developed by the Agency for Healthcare Research and Quality (AHRQ).² Steps you can take as senior leadership include:

1. Implement and empower a Care for the Caregiver team to carry this work forward
2. Establish clear team goals and set an expectation of accountability
3. Establish organization-wide expectations for the program
4.  Provide ongoing senior leader level support for the work

Pennsylvania is committed to caring for our caregivers. All acute care facilities in Pennsylvania are invited to join with their colleagues in implementing CANDOR across the Commonwealth. The Patient Safety Authority (PSA) has partnered with the MedStar Health Research Institute to bring a coordinated approach to the rollout of this critical work statewide. Education modules and customized support will be available to all licensed acute care facilities in Pennsylvania who register to participate in one of the upcoming PSA-sponsored cohorts.

The commitment deadline for cohort 1 is March 31, 2021. If you are interested, please send an email to ra-patientsafetyauthority@pa.gov.

Citations:

1.Wu AW. Medical Error: The Second Victim. The Doctor Who Makes the Mistake Needs Help Too. BMJ. 2000;320(7237):726–727. doi:10.1136/bmj.320.7237.726

2.https://www.ahrq.gov/patient-safety/capacity/candor/modules/notes6.html