Guilty, afraid, and alone--struggling with medical error.

n engl j med 357;17 www.nejm.org october 25, 2007 1682 S 1999, health care professionals have been focusing on To Err Is Human, the Institute of Medicine report that sounded alarms about medical error. As we have strived to reduce the rate of errors, systems-based practices such as electronic order entry and procedure checklists have proliferated. Meanwhile, little attention has been paid to the second half of the adage — “to forgive, divine.” How can we characterize and address the human dimensions of medical error so that patients, families, and clinicians may reach some degree of closure and move toward forgiveness? In interviews that our group conducted for a documentary film, patients and families that had been affected by medical error illuminated a number of themes.1 Three of these themes have been all but absent from the literature. First, though it is well recognized that clinicians feel guilty after medical mistakes, family members often have similar or even stronger feelings of guilt. Second, patients and their families may fear further harm, including retribution from health care workers, if they express their feelings or even ask about mistakes they perceive. And third, clinicians may turn away from patients who have been harmed, isolating them just when they are most in need. Despite acknowledging that they probably could not have prevented the error, family members often berate themselves and feel guilty about not keeping close enough watch. A young man with sickle cell anemia and well-documented life-threatening reactions to morphine received this medicine despite his family’s repeated warnings. When renal failure and coma resulted, his sister noted, “The feeling was impotence, because you can’t stay with a patient 24 hours a day. That’s why you rely on hospitals — you rely on nurses. You feel like you failed your family in terms of ‘I should have been there.’ That’s a guilt that everyone shares.” Guilt persists in the daughter of a woman who died after a series of errors culminating in a missed case of pneumonia. Although the daughter is a nurse, she could not gain entry into her mother’s circle of clinicians, who closed ranks after the errors occurred. “The nurses were ruder to me than you can ever imagine, and the doctors wouldn’t tell me anything,” she said. “They looked at me like I was a dumb little girl. I became so addled that I couldn’t act decisively and get her out of there to another hospital. I’ll never get over my guilt.” Clinicians who feel guilty after a medical error may have parallel feelings of fear — fear for their reputation, their job, their license, and their own future as well as that of their patient. Although full disclosure of medical errors is increasingly recognized as an ethical imperative, health care providers often shy away from taking personal responsibility for an error and believe they must “choose words carefully” or present a positive “spin.”2 Hospitals, insurers, and attorneys frequently advise physicians against using trigger words, such as “error,” “harm,” “negligence,” “fault,” or “mistake.” The result can be an impersonal demeanor that leads patients to view physicians as uncaring. To date, approximately 30 U.S. states have adopted “I’m sorry” laws, which to varying degrees render comments that physicians make to patients after an error inadmissible as evidence for proving liability.3,4 However, until such statutes become universal and are accepted by health care institutions, frightened clinicians are left to struggle with conflicting personal moral principles, professional ethics, and institutional policies. The patients and families interviewed for the film also spoke of fear — indeed, fear of retribution or future poor treatment was the reason most frequently cited for declining to be interviewed. Because of the power dynamics between physicians and patients, questioning the expertise or skill of an authority figure is particularly fraught for the least empowered members of society — members of minority groups, immigrants, and non-native English speakers. Several such persons who were approached for interviews feared they would be investigated and possibly punished by “the authorities” if they told their stories. More strikingly, some patients and family members were afraid that confronting medical personnel might lead to further injury. Explained one patient whose subdural hematoma had been missed by clinicians: “I was frightened to complain any more — scared that, you know, you hear about people being mistreated in the hospital. I was scared that I would get more mistreated.” Given the nature of the emotions provoked by medical error, feelings of isolation can be particularly harmful. Family members of injured patients told us, “What we needed was for someone to Guilty, Afraid, and Alone — Struggling with Medical Error