Dimensions of medical errors – The three victims and defensive medicine

Abstract

Background

Despite recent advances in medical sciences, the utilisation of technology, and the spread of awareness on patient safety, medical errors still occur and impose a significant burden on healthcare facilities and society. Safety incidents have an impact on the doctor–patient relationship, leading to a defensive medical practice.

Objective

This narrative review aims to present an overview of the dimensions of medical errors and their consequences, with a focus on the second victim phenomenon and defensive medicine.

Methods

Search of the PubMed-indexed relevant publications in the English language. The full texts of the relevant publications have been summarised.

Results

This review explored the dimensions of medical errors and their consequences. The second victim phenomenon describes the physical symptoms and emotional experience of the healthcare practitioners involved in safety incidents. There is a limited number of structured support programs to help the second victims. Unfair media coverage of medical errors adds pressure and directs the blame rather than contributing to solving the problem. Defensive medicine originated due to the increasing litigation claims and represents a fundamental change in the doctor–patient relationship. It takes two forms: positive and negative defensive medicine.

Conclusions

This multidimensional presentation of the topic may be helpful to readers involved in such incidents or working to mitigate their consequences. Patients should understand they are not the only victims of the harm imposed on them. The staff involved should seek help, and healthcare facilities should offer support programs for staff involved in safety incidents. The general audience should receive the published material about medical errors in a reasonably neutral manner and avoid one-sided presentations in the media.

Keywords

medical errors patient safety second victim healthcare institutions defensive medicine litigation healthcare costs

Background

The inherited social position of the physician within society ingrained a heroic picture of the infallible physician. Moreover, the recent advances in laboratory sciences, imaging, and diagnostics have founded the base for the public belief in zero errors. They raised the expectations to the highest level, where there was no place for any mistake.¹ However, this is not the reality; mistakes happen. Healthcare professionals are meant to treat their patients in healthcare facilities. Mistakes flow like a domino effect with negative consequences on three victims: the first victim is the patient (and their families), the second victim is the healthcare professional involved, and the healthcare facility is the third.^2,3

Methods

Aim of work

This narrative review aims to present a comprehensive overview of the dimensions of medical errors and their consequences on patients, healthcare staff, and facilities. Additionally, it presents an explanation of the second victim phenomenon, as well as the origin and forms of defensive medicine.

Research questions addressed

1. What are the consequences of medical errors?

2. Is there a detailed description of the second victim phenomenon? Are there formal support programs for the second victims?

3. How did defensive medicine practice arise, and what are its forms and consequences?

Literature search

Search of the PubMed database using the following keywords: medical errors, medical mistakes, consequences of medical errors, media coverage of medical errors, second victim, support of the second victim, and defensive medicine.

Inclusion criteria

PubMed-indexed publications in the English language published at any time.

Data synthesis

The full texts of the relevant publications have been summarised under four main sections: The First Victim – Magnitude of the Problem in the Modern Era, The Consequences on the Healthcare Professional Involved – The Second Victim, The Healthcare Facilities – The Third Victim, and Defensive Medicine. Data saturation was achieved after answering the intended research questions.

Literature review

The first victim – magnitude of the problem in the Modern Era

In 2000, two landmark reports were published that changed the history of patient safety. The first was published by the United States (US) Institute of Medicine,⁴ and the other was released by the Department of Health in the United Kingdom (UK).⁵ Based on real studies of medical errors in the US,^6,7 the American report stated that with 33.6 million admissions to US hospitals in 1997, they extrapolated that 44,000–98,000 Americans die in hospitals each year due to medical errors. They stated that deaths in hospitals due to preventable adverse events exceed the number attributable to the 8^th leading cause of death. Deaths due to preventable adverse events exceed the deaths attributable to motor vehicle accidents, breast cancer or AIDS.⁴ The report also highlighted medical errors occurring outside hospitals, including those made by community pharmacists.

The report released by the Department of Health⁵ in the UK suggested that adverse events occur in 15% of all hospital admissions, giving rise to 850,000 incidents annually, half of which are potentially avoidable. Based on the reporting system adopted at that time, it was estimated that 2500 serious incidents were reported annually across the UK. Moreover, more than 6,600 adverse incidents involving medical devices were reported to the Medical Devices Agency in 1999, with many incidents resulting in death and serious injuries.

Another study⁸ conducted in Australia, reviewed 14,000 admissions to 28 hospitals and revealed adverse events in 16.6% of admissions, more than half of which were deemed preventable. These reports shocked the world and highlighted the suffering of the first victims in the healthcare facilities in the developed world.

The consequences on the healthcare professional involved – The second victim

Involvement in any medical error does not go without a cost to the healthcare practitioner. It has a recognised spectrum of physical, emotional, and professional consequences. This led to the introduction of the term (Second victim), first coined by Wu.⁹ Healthcare practitioners often experience conflicting emotions, including guilt, fear, and remorse. Fear of punishment, anger, and reputation, guilt due to the feeling of responsibility for the patient and their trust in their physician, and regret of missing out on the preventative measures or causing harm. This situation leads to an inner conflict.^9,10

Recent studies describe the wide range of symptoms experienced by the second victim as resembling post-traumatic stress disorder and are physical and psychological in nature. Physical symptoms include gastrointestinal manifestations such as nausea, vomiting, diarrhoea, sleep disturbance, headache, fatigue, lack of concentration, and poor appetite. The psychological symptoms include depression, social isolation, fear, anger, irritability, sadness, and lack of confidence. Professional consequences add to the suffering of the second victims. Physicians involved in such incidents are exposed to litigations, potential loss of licence and job, negative reputation, and lack of respect and support.^11–14 This leads to avoidance behaviour and self-doubt, resulting in poor performance and another error, creating a vicious circle that overwhelms the second victim and destroys them completely.^10,15,16

The effect of a medical error on a healthcare professional is an interaction between two variables (Effector and recipient), and the outcome is determined by the qualities of these two variables. The available literature examined the relationship between the severity of the medical error, or the level of harm imposed on the patient and the consequences on the healthcare professional. However, these studies present conflicting findings without solid conclusions. Generally, the severity of medical errors can be classified according to the WHO classification (Table 1).¹⁷

Table 1.

WHO classification of the levels of harm.

Level of harm	Explanation
None	Patient outcome is not symptomatic, or no symptoms detected, and no treatment is required
Mild	Patient outcome is symptomatic, symptoms are mild, loss of function or harm is minimal or intermediate but short term, and no or minimal intervention (e.g. extra observation, investigation, review, or minor treatment) is required
Moderate	Patient outcome is symptomatic, requiring intervention (e.g. additional operative procedure and additional therapeutic treatment), an increased length of stay, or causing permanent or long-term harm or loss of function
Severe	Patient outcome is symptomatic, requiring life-saving intervention or major surgical/medical intervention, shortening life expectancy or causing major permanent or long-term harm or loss of function
Death	On balance of probabilities, death was caused or brought forward in the short term by the incident

Additionally, the NHS policy guidance on recording patient safety events and levels of harm¹⁸ presents a more detailed classification, distinguishing physical from physiological harms. It is based primarily on the effects of the incidents on the patient, the remedial measures needed to treat the harm, and their duration.

A study¹³ included 4,369 respondents from 32 Dutch hospitals who were involved in patient safety incidents (PSI). There were 462 participants involved in a PSI with permanent harm or death during the last 6 months. The impact of a PSI increased according to the degree of patient harm. PSI with permanent harm or death was related to an eightfold higher likelihood of staff symptoms lasting for more than 1 month and a nine-fold likelihood lasting longer than 6 months compared with symptoms after harmless PSI. They concluded that the higher the degree of harm, the longer the duration of symptoms.

These results have been reproduced in another study of Swiss anaesthesiologists.¹⁹ However, a survey²⁰ of 265 physicians and nurses conducted in two teaching hospitals in the UK and the US showed that the emotional response and coping strategy did not differ based on the harm.

Other studies examined the effect of the attributes of the healthcare provider involved on the severity of the second victim phenomenon. A cross-sectional survey²¹ included 1,163 nurses from an acute public hospital in Singapore found that younger and less experienced nurses were more likely to experience a greater second victim response. Another study involving 536 nurses²² showed that positive responses from senior staff, accepting responsibility for errors, and seeking social support predicted constructive changes in nursing practice. In contrast, negative reactions from senior staff and error-escape avoidance predicted defensive changes.

Other studies²³ showed that seeking social support and problem-solving focused on addressing the factors contributing to the error are significant predictors of constructive changes in practice among perioperative nurses. Additionally, coping approaches, conversations, and learning activities may influence the relationship between making an error and the emotional impact on the staff and the resultant practice change.²⁴ A study included 378 Korean staff nurses²⁵ involved in PSI showed that lower organisational support and higher non-work-related support were associated with severe symptoms. Participants with severe symptoms agreed more with the usefulness of the support strategies, including psychological support.

The University of Missouri’s (MU Health) forYOU support program outlines the different stages the second victim goes through during the recovery from such incidents.²⁶ In 2007, an important article (TRUST)²⁷ established the fundamental rights of healthcare professionals involved in medical errors. TRUST is an acronym for these basic principles, including treatment that is just, respect, understanding and compassion, supportive care, and transparency and opportunity to contribute.²⁸ The Joint Commission recommends that healthcare organisations should have a program to support second victims.²⁹

There are limited resources to help the second victim recover from this overwhelming burnout and failure.^16,29 A deeper search showed some sporadic programs designed to support second victims. ForYOU³⁰ is a three-tier program designed by the University of Missouri to provide one-on-one support to the second victim throughout the recovery process. Johns Hopkins created the RISE (Resilience in Stressful Events) program,³¹ which takes the form of one-on-one or group support. It is a 2-tier system with multidisciplinary peer responders on call at any time. YOU Matter³² is a program implemented in the Nationwide Children’s Hospital with more than 700 peer supporters. It also has a critical response team that manages situations involving more than five staff members or multiple departments.

The Yorkshire Quality and Safety Research Group and the Improvement Academy designed another platform in 2019. The website³³ provides support and guidance for healthcare professionals and their organisations through three tiers of support. Other programs providing structured formal responses through escalating levels of interventions have been identified.^34,35 The Second Victim Experience and Support Tool (SVEST)³⁶ was developed to guide healthcare facilities and assess their performance regarding the support delivered to second victims.

The healthcare facilities – Third victim

The impact on healthcare facilities where medical errors occur extends beyond the costs related to compensation and settlements of claims into the negative impact on the reputation and enrolment of new patients in the services. Unobjective media coverage of medical errors plays a part. It highlights the failure and directs the blame and accusations instead of providing comprehensive, logical coverage that aims to provide solutions and prevent similar incidents.^37,38

In the United States, it was estimated that total national costs for adverse events ranged between $37.6 billion and $50 billion and between $17 billion and $29 billion for preventable adverse events. The total national costs of adverse and preventable adverse events represented at least 4% and 2% of national health expenditures in 1996, respectively. In 1992, the costs of adverse events were higher than the costs of caring for people with HIV and AIDS.⁴

Medical errors do not occur only in hospitals; these incidents can also happen in outpatient settings. In the UK National Health Service (NHS), adverse events result in a direct cost of £2 billion for additional hospital stays. In 1998/1999, the NHS paid around £400 million in clinical litigation settlements. In the same year, there were over 38,000 complaints about all aspects of family health services and nearly 28,000 written complaints about clinical treatment in hospitals alone.⁵

The most recent data from the UK showed payments for resolving clinical claims in 2023/24 of £2,821 million. This includes damages paid to claimants of £2,107 million, claimant legal costs of £545 million and NHS legal costs of £169 million. The Clinical Negligence Scheme for Trusts (CNST) had 10,834 claims and reported incidents across primary and secondary care in 2023/24 compared with 10,567 in 2022/23. The estimated cost of harm of this scheme in 2023/24 was £4,778 million, and in 2022/2023, it had an estimated cost of £6,278 million.³⁹

Another consequence on healthcare organisations is the negative reputation that results from unfair media coverage. A study of 64 articles in six countries and regions⁴⁰ showed that reports of medical errors presented the point of view of patients and legal professionals in 30%, and that of a safety expert or the responsible clinician in 13% and 3%, respectively. The articles attributed 41% and 28% of errors to the responsibility of individual clinicians and hospital systems, respectively. Four in 10 articles did not present medical errors as “systems” problems. The study concluded that media regularly blame individual clinicians for mistakes and fail to show a systems-based understanding of these incidents. Another study demonstrated that facilities that had published reports of adverse events had lower enrolment rates after publishing the reports.³⁸

Defensive medicine

The severity of the impact of medical errors on healthcare professionals and organisations led to fundamental changes in the relationship between the patient on one side and the physicians and healthcare facilities on the other. There was a change in the concept of medical liabilities from the act of commission to the act of omission. Initially, most of the litigation claims were related to surgery or medical treatment that led to patient harm. However, at the peak of the litigation claims crisis in the US in the 1970s, there was a significant change in the nature of claims, including missed diagnoses or wrong interpretations of diagnostics.^(41–43) An article by the American College of Radiology in 1985⁴⁴ showed that missed fractures or dislocations were the leading cause of radiologic lawsuits in the US, followed by claims of failure to diagnose cancer. The problem extended to include claims against physicians because they did not order specific diagnostic tests. A study conducted in 1991⁷ showed that 75% of all adverse events due to negligence in New York hospitals in the late 1980s were related to diagnostic tests, usually due to a physician’s failure to do something. The unprecedented surge in litigation claims led to increased average premiums paid by healthcare practitioners and hospitals. It has been clear that the origin of the problem lies in the high expectations and the culture of zero mistakes. The technological revolution and the adoption of high technological advances in medicine led to a false belief that there is no place for errors and that the human body could be looked after similarly to a computer or a machine. This put much pressure on the physicians and healthcare facilities to defend themselves from any intentional or unintentional mistakes that could arise along the way.^45,46 This dramatically changed the healthcare culture and the ethical bond between patients and physicians. Eventually, it led to the birth of a new kind of medicine – defensive medicine – where the fear of litigation and self-protection from the patient replaced the ethical commitment to work for the patient’s best interest.¹⁶ This kind of practice entails overutilisation of tests and diagnostics and the overtreatment of mild conditions when the risks could outweigh the benefits. These practices could be described as positive defensive medicine. Avoidance of high-risk patients, therapeutics or procedures was also meant to escape medical liabilities in cases of failure or complications; this practice formed the basis of negative defensive medicine.^47–49 Regardless of the different definitions proposed for this phenomenon, the most relevant is the change in the paradigm of working for the patient’s best interest to working for self-protection.

The wide adoption of this practice is multifactorial. A recent scoping review⁵⁰ that included 13 publications revealed four main categories of factors influencing defensive medical practice: (social) media, patients adopting a consumer attitude, healthcare system working conditions, and physicians’ tolerance for uncertainty. These factors interplay and exert massive pressure on healthcare practitioners to adopt the defensive medicine attitude.

This kind of practice has become the standard medical practice. A survey of high-risk specialists in Pennsylvania revealed that 90% practice defensive medicine.⁵¹ Another survey of more than 1200 physicians across various medical specialities revealed similar findings: 91% ordered more tests and procedures than needed to protect themselves from malpractice suits.⁵²

Paradoxically, this practice has not led to a reduction in medical errors. On the contrary, the available evidence suggests that defensive medicine, where physicians discover milder illnesses and over-treat mild conditions, has led to a new surge in errors of commission. Overall, defensive medicine increases the cost of medical care and places a greater burden on patients and healthcare organisations. In the United States, the cost of defensive medicine was estimated to range from $45.6 billion to $650 billion annually.^53,54 Defensive medicine costs in the US account for more than 80% of the total yearly cost of the medical liability system.⁵⁵ The number of malpractice litigations in Europe has increased significantly over the last decade (from 50% in Britain, Scandinavia, the Baltic countries, and Eastern Europe to more than 200% in the Mediterranean countries).⁵⁶ A study published in 2015 by the Italian Ministry of Health estimated that defensive medicine costs represent the first category of healthcare waste, accounting for 0.75% of the Italian GDP.⁵⁷

Despite these facts, defensive medicine has perpetuated. A survey of medical students and residents at a university academic medical centre found that 94% of students and 96% of residents have seen or experienced examples of defensive medicine during their clinical training. Additionally, 34% of the students and 43% of residents saw physicians avoid providing services to patients for fear of medical liability.^45,58 Another aspect that potentially promoted the practice of defensive medicine is the culture of guidelines. Despite the advantages of standardising diagnostic algorithms and medical management, following guidelines blindly without considering the patient’s specifications and presentation could be a form of defensive medicine, adopted for self-protection by following a set of agreed-upon steps established by national or international professional entities.^59–61

This review provides a succinct summary and insight into the consequences of medical errors. Anyone involved in such incidents (patients, healthcare professionals, and organisations) could find this content helpful in understanding the holistic picture.

Conclusions

• Medical errors have multidimensional consequences. Besides the physical and mental harm imposed on the patients and their families, medical errors affect the staff involved and their facilities.

• The second victim phenomenon describes the physical symptoms and emotional experience of the healthcare practitioners involved in safety incidents. A limited number of structured support programs exist to help the second victims.

• This review highlighted the cost of medical errors and the financial burden on healthcare facilities. Media coverage of medical errors could be unfair, adding pressure and directing the blame rather than contributing to solving the problem.

• Defensive medicine originated due to the increasing litigation claims and represents a fundamental change in the doctor–patient relationship. It takes two forms: positive and negative defensive medicine. Overall, defensive medicine has complicated the problem more and has not reduced medical errors.

Implications

This comprehensive, multidimensional presentation of the topic may be helpful to readers involved in such incidents or working to mitigate their consequences. Patients should understand they are not the only victims of the harm imposed on them. The staff involved should seek help and appreciate the potential serious consequences. Healthcare facilities should offer support programs to their employees who are involved in safety incidents. The general audience should receive the published material about medical errors in a reasonably neutral manner and avoid judgmental, one-sided presentations in the media.

Limitations

Due to the lack of clear guidelines for conducting narrative reviews, the data included were based on the designed inclusion criteria. They might not follow an exhaustive search, rigorous methodology, and reporting standards as in systematic reviews, which opens the door to selection bias.

Supplemental Material

Supplemental Material - Dimensions of medical errors – The three victims and defensive medicine

Supplemental Material for Dimensions of medical errors – The three victims and defensive medicine by Mohamed Abosheisha and Islam Omar in International Journal of Risk & Safety in Medicine

Footnotes

ORCID iD

Islam Omar

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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