Medical Error Is a Fact - How We Respond Is a Choice

Patricia I. McCotter, RN, JD, CPHRM, CPC, Director of Facility Risk Management and Provider Support, and Ron Hofeldt, MD, Director of Physician Affairs

Mistakes happen. In fact, as many as seven out of 100 hospital admissions involve a serious medical error, according to Don Berwick, MD, of the Institute for Healthcare Improvement. Because humans are prone to making mistakes—regardless of their training—it’s not a matter of asking if errors will occur, but when. Thinking about your own care setting, how would you and your facility support a coworker if an adverse event occurred today?

Some settings and specialties carry higher risk: intensive care units, operating rooms, code teams, emergency medicine, pediatrics, obstetrics, oncology, and palliative care. But adverse events are not limited to these environments.

When an event occurs, the clinicians who are involved typically respond three ways. For some, a first instinct is to drop out of the profession. Others survive the event and cope, but may be haunted with sadness and thoughts about the event or even resort to addictive behaviors to cope. Others choose to thrive. They do so by practicing self-care, by maintaining a good work/life balance, and by gaining wisdom from the experience. They realize they needn’t define their practice or career by the single event. Some clinicians recover by advocating for patient-safety initiatives.

Organizations and peers can help

Coworkers and organizational leaders can support colleagues by knowing how to respond when an error occurs. Department or unit leaders can reach out, demonstrating a caring attitude and conveying faith in the provider’s clinical skills. They can also offer the employee flexible scheduling as needed. Additionally, leaders can brief the employee on any investigation that may occur, and they should be visible and transparent to all staff on the unit. Peers can be supportive by actively listening to what their coworker wants to express. Swapping “war stories” provides an outlet for stress.

Another best practice is to deploy multidisciplinary rapid-response teams, especially in high-risk areas, to reach out to clinicians as part of a formal provider support program. These employees are specially trained to monitor colleagues for second-victim signs and provide support. Organizations can also develop external referral networks, which might include employee assistance programs, social workers, chaplains, and clinical psychologists.

AVERT Training and Support

As a free service, Physicians Insurance offers Adverse Event Response Team (AVERT) Program training to policyholders. The 2½-hour program teaches health care providers ways to address the needs of patients, families, caregivers, and facilities following an adverse event. The goal is to ease the traumatic effects of a poor medical outcome on the patient and health care team, and the curriculum can be tailored for your organization.

To inquire about AVERT training, please contact Patricia McCotter, RN, JD, the company’s director of facility risk management and provider support, at or (206) 343-7300.