Medical Errors Hurt Doctors, Too

Doctors and nurses make mistakes, some of which hurt patients. To err is human. In fact, that’s the name of a 2000 Institute of Medicine report aiming to decrease errors in health care.

Calcium chloride photo by Markus Brunner (Wikimedia Commons)

The Institute for Safe Medication Practices (ISMP), a non-profit that focuses the bulk of its work on improving patient safety, also recognizes that a patient injured by a medication error isn’t the only one hurting after the mistake. A recent newsletter and press release draw attention to the so-called “second victims” of medication errors — the healthcare workers who are involved in the error.

Healthcare workers may react with feelings of sadness, fear, anger, and shame, and be haunted by the incident. They may lose confidence, become depressed, and even develop PTSD-like symptoms.

A case in point: Kimberly Hiatt, a pediatric critical care nurse with 27 years of experience, made a mathematical error that resulted in an overdose of calcium chloride in a fragile infant. The baby died. Hiatt’s life went into a tailspin. She felt consumed by guilt. She lost her job and, despite obtaining extra training, she was unable to find work. Seven months later, she committed suicide in April 2011.

The ISMP says a culture of silence and lack of support surrounds medication errors in healthcare, and it points healthcare workers to resources to change that culture. For example, you can watch a free webinar about the second victims of medical error, produced by the Texas Medical Institute of Technology. A toolkit for building a support program for clinicians and staff is available from the Medically Induced Trauma Support Services.

If you’re a healthcare worker, what’s it like at your institution when medication errors happen? Does anyone ever hear about them? Are there mechanisms in place to learn from mistakes? Is there any structural support for healthcare workers who make a mistake?

Have you ever had to deal with a medication error or other medical error of your own? How did you cope?

Leave a comment and let us know.

—Sherry Boschert (on Twitter @sherryboschert)

Recession Leads To More Suicides, Fewer Car Crashes

The worldwide banking and financial crisis that started in the summer of 2008 led to many casualties beyond the ones that make the headlines, such as people who have lost jobs or defaulted on their mortgages and lost their homes. A new analysis published in The Lancet calculates the literal casualties — people who have died. More specifically, Europeans who committed suicide or were killed in vehicle accidents.

Cars in The Netherlands (Photo by Komencanto, Wikimedia Commons)

In all but one country, suicide rates jumped with unemployment rates, according to the letter by David Stuckler of the sociology department at the University of Cambridge, United Kingdom, and his associates (Lancet 2011;378:124-125).

On the other hand, road deaths declined, probably due to higher unemployment leading to less car use. And there’s an important side effect from this. The availability of organs for transplants, which come mainly from motor vehicle accidents, declined substantially in Spain and Ireland, where traffic deaths dropped more than 25% between 2007 and 2009.

In the end, did more people live or die from the financial crisis? The authors didn’t say, but I did a few rough calculations below. Plus, the study did not estimate potential deaths caused by the decrease in available organs for transplant, so we’ll have to ignore that for now.

First, some of the study’s findings. Complete data were available only from 10 countries, which the investigators divided into two groups for comparison. Six were in the European Union before 2004 (Austria, Finland, Greece, Ireland, the Netherlands, and the United Kingdom), and four were in the expanded EU after 2004 (Czech Republic, Hungary, Lithuania, and Romania).

Across the EU as a whole, unemployment jumped nearly 3% (a 35% relative increase) from 2007 to 2009. While suicide rates had been trending downward before 2007, that trend reversed with the financial meltdown. In 2008, suicide rates increased by 7% in the old EU countries and increased further in 2009. The newer EU states seemed a bit more resilient, with less than a 1% increase in suicide rates in 2008 and further increases in 2009.

Traffic fatalities declined in each country, to a degree influenced by pre-recession rates. Lithuania’s high pre-recession rate of road deaths decreased by nearly 50%, while the already low rate of traffic fatalities in the Netherlands left little room to shrink. Other data show a similar trend in the United States during this period, when traffic fatalities declined by more than 10% to the lowest level ever reported, they said. (They didn’t mention U.S. suicide rates.)

The countries facing the greatest financial crises saw the greatest increases in suicide rates, by 17% in Greece and Lithuania, and by 13% in Ireland.

To give one example of absolute numbers, the United Kingdom’s suicide rate rose from a low in 2007 of 6.14 per 100,000 people under the age of 65 years to a 2008 rate of 6.75 per 100,000 people younger than 65, a rate that stayed steady in 2009. Traffic fatalities fell from 4.92 to 3.68 per 100,000 population from 2007 to 2009.

The anomaly was Austria, where suicides declined by 5% between 2007 and 2009. Previously, the authors had speculated that suicide risk might be mitigated in countries with formal and informal social protections, such as active labor market policies and strong social networks. That description fits Austria. But that description also fits Finland, where they unexpectedly saw a 5% increase in the suicide rate, counter to historical trends in previous recessions.

Here’s where I go rogue and try to crunch some numbers using these findings, using just the U.K. as an example. The U.K.’s Office of National Statistics pegged its population at 62,262,000 in mid-2010, and 83% was younger than 65 years (51,677,460). Let’s very roughly assume the same population existed in 2007 and 2009.

Applying the rates reported in The Lancet, 32 more people would have killed themselves in 2009 than in 2007, but 77 fewer people would have died from vehicle accidents in 2009 compared with 2007. Overall, 45 more people would be alive in 2009, probably because the recession made it financially too difficult to drive as much they did before.

Seems to me there are two morals to this story. Financial crises can be fatally hard on the human psyche. And cars are dangerous. I’m in favor of policies that help us avoid both.

–Sherry Boschert

Reflecting on Body Dysmorphic Disorder

The nature of body dysmorphic disorder is that someone is suffering because of their perceived (not objective) flaws in appearance. I didn’t understand how much people suffer, and the potential severity of this disorder, until I covered a talk by Dr. Katharine A. Phillips at the annual meeting of the American College of Psychiatrists.

Image courtesy of flickr user Jo Naylor (Creative Commons license).

It goes beyond suffering. Body dysmorphic disorder can be life-threatening. Patients have been known to pick at a “blemish” on their skin so obsessively that they dig down to an artery, and need emergency surgery to stop the bleeding.

The psychological distress is so severe that 24%-28% of people with body dysmorphic disorder try to kill themselves. And many succeed. Dr. Phillips said she has preliminary data suggesting that the annual rate of completed suicides is 22-36 times higher among people with body dysmorphic disorder compared with the general population.

This is not a rare disorder. Its prevalence has been reported as approximately 2% in nationwide epidemiologic studies, or 2%-13% in nonclinical student samples. Students? Yes — body dysmorphic disorder most commonly first appears at 13 years of age. And not just in females. Males may be as likely to develop body dysmorphic disorder, typically thinking they are too small or thin (one factor behind the dangerous use of steroids).

See my full report on Dr. Phillip’s talk soon in Clinical Psychiatry News. In the meantime, if you’re a clinician doing cognitive behavioral therapy with patients who have body dysmorphic disorder, Dr. Phillips strongly recommends a book for you to have and read: “Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications” (American Psychological Association, 2008).

— Sherry Boschert (@sherryboschert on Twitter)

Video of the Week: Dealing With Suicide

For psychiatrists, dealing with suicide comes with the job. 

The nature of our work is such that we do look after people with serious mental illnesses.  It’s known that somewhere between 85% to 95% of people who die by suicide have been living with some type of psychiatric illness, whether it’s been treated or not.

— Dr. Michael F. Myers

While at the annual meeting of the American Society of Suicidology, reporter Damian McNamara talked with Dr. Michael Myers (SUNY-Downstate Medical Center) about how psychiatrists can cope with the suicide of a patient or colleague.  His first piece of advice: Don’t isolate.

For more great videos and the latest medical news, check out our new Internal Medicine News Web site.

BP’s $20 Billion: Not A Single Dollar For Health

The Washington Post reported today that an Alabama fisherman working on the BP oil spill clean-up committed suicide on Wednesday, making him perhaps the first post-accident casualty, and reflecting what may end up being a deeper and longer-lasting impact on the Gulf States’ psyche than Hurricanes Katrina and Rita.

That region, particularly the New Orleans metropolitan area and the Mississippi coast, has still never truly recovered from those storms, emotionally, physically or financially. There is very little capacity to cope with a new disaster, especially one that appears to have no end in sight.

Via Flickr Creative Commons user Infrogmation

And yet when the White House announced last week that it had secured a promise from BP to set aside $20 billion in assets to mitigate the costs of the spill, not a single penny of that was earmarked for physical or mental health services. Importantly, it will pay claims for economic distress and damage, and will help rebuild the seafood, oil and gas services, and tourism industries.

But what about the health of those expected to be a part of that rebuilding? Yesterday and today I spoke with physicians who are scrambling to respond to what appears to be a slowly unfolding mental health crisis.

Dr. Chuck Coleman, a psychiatrist who helps run the St. Bernard Project’s Center for Wellness and Mental Health, said that there has been an increase in symptoms for those who were already anxious or depressed, and a noticeable increase in substance abuse and domestic violence. The Project is turning to the wives of the men who can no longer fish, shrimp or dredge for oysters, using them to conduct outreach and make referrals.

But, as Dr. Coleman notes, this also is not a group of people who are comfortable seeking mental health services. That was echoed by Dr. Ben Springgate, a Tulane University internist, who along with colleagues, has been conducting training sessions for organizations such as the Mary Queen of Viet Nam Community Development Corp.  The idea is for each community to reach out to its own in a culturally appropriate fashion — something that has been a goal nationally for health care providers.

Dr. Springgate noted that while it was well and good for state and federal officials to expect BP to pay for all costs related to the spill, the reality is that health care is being overlooked. He claimed that the state of Louisiana had asked BP for a fund to monitor long term health effects, and for a $10 million disbursement to cover short term mental health needs.  The company refused both, he said.

Hopefully, it won’t take the collapse of a community — or multiple suicides — to bring quick resources to the region.

— Alicia Ault (on Twitter @aliciaault)

When Psychiatrists Experience Suicide

from the American Association of Suicidology annual meeting in Orlando 

It’s not uncommon for psychiatrists to lose a patient to suicide at some point during their training or careers. In fact, about half will, according to a study in 2004. 

John L. McIntosh, Ph.D. (photo by D. McNamara)

These “clinician survivors” should not isolate themselves. Instead, they should talk with colleagues, family, and friends, John L. McIntosh, Ph.D., of Indiana University, South Bend said. This helps physicians avoid some of the adverse effects: 

• Fear of blame from the patient’s family
• Feelings of guilt or responsibility
• Doubts about professional competency

  Although few psychiatrists leave the field following a client suicide, many change the way they practice, Dr. McIntosh said. 

The American Association of Suicidology maintains a ListServe where psychiatrists can discuss their feelings about client suicide anonymously, Dr. Michael F. Myers of SUNY Downstate in Brooklyn said at the  meeting. 

Michael F. Myers, M.D. (photo by D. McNamara)

In addition, professional counseling can help after client suicide, as it helped Dr.  Myers. He had a roommate in medical school, a fellow medical student, who committed suicide. Later, three patients committed suicide during his training (most psychiatry residents experience this once or not at all during their training, he said, but he was seeing a high-risk population). At the time he felt “responsible, inadequate, confused” and feared his peers would judge him. 

He’s come a long way. “Losing patients to suicide is part of one’s job as a psychiatrist,” Dr. Myers said. “Admit the limitations of our ability to help. Our goal is to help people with mental suffering. All we can do is try our best.” 

–Damian McNamara

Grown Up Pains

Vancouver may be buzzing with the excitement of the Olympics but on the evening of Feb. 25, friends of former “Growing Pains” sitcom star Andrew Koenig found his dead body in an urban park. He’d been missing in Vancouver since Valentine’s Day. He was 41 and had long battled depression. 

“My son took his own life,” his father, Walter Koenig, best known for his role as Chekov on the original “Star Trek” television series, said during a heart-wrenching press conference held in the chilly outdoors. “He was obviously in a lot of pain.”

The incident is a sobering reminder of depression’s impact on society. According to the National Institute of Mental Health, the majority of your patients with depression do not commit suicide, but having the disease does increase their risk. The NIMH also notes that more than four times as many men as women die by suicide in the United States, even though women make more suicide attempts during their lives.

During the press conference, Mr. Koenig made a plea to remind us all not to ignore loved ones, friends, or patients who may be suffering from depression.

 “If you’re one of those people who feel they can’t handle it any more, if you can learn anything from this, it’s that there are people out there who really care,” Mr. Koenig said. “You may not think so, but there are people who really care. Before you make that final decision, talk to somebody. And for those families who have members who they fear are susceptible to this kind of behavior, don’t ignore it; don’t rationalize it. Extend a hand.” 

–Doug Brunk (on Twitter@dougbrunk)