The outreach program at Dr. Shapiro’s institution involves a clinician colleague trained to provide peer support. “Because there are so many cultural, emotional, legal, and structural barriers to seeking help, we have found that even if support is available, most clinicians won’t seek it,” she said. “Therefore, a trained peer reaches out to clinicians after an error has occurred and asks if they want support.”
Explore This IssueDecember 2015
The colleague providing support will validate the fact that it is normal to struggle after something bad happens, such as inadvertently causing harm. “It is human and OK to have such feelings,” Dr.
Shapiro said. Then, the peer supporter will help the clinician to identify which coping tools might help him to move forward. The peer supporter may help the clinician explore what has helped him to cope with difficult life events in the past and encourage him to employ those methods in this instance.
The peer support process can also involve encouraging the clinician to be involved in system changes, so he can not only help himself but also help colleagues learn from systems issues, making the system safer moving forward. “Making things better helps the doctor, helps other clinicians, and, most importantly, helps future patients to avoid the same scenario,” Dr. Plews-Ogan said.
Studying Error Occurrences
Admitting errors, learning how to prevent them, and moving on from them continue to be growing topics in the literature. Dr. Wax and colleagues were prompted to study and publish a paper on the accidental dropping or misplacement of free flaps after a free flap was misplaced in the operating room (Laryngoscope. 2015;125:1807-1810). This had happened sporadically a few times before. “It was supposed to be on the back table, waiting to be implanted into the patient, and when we asked the tech for it, she found it in the recycling bin,” he said. “When unfortunate things happen in the operating room, we need to look at the cause and see if there is something we can do about it.”
Dr. Wax reached out to his colleagues with high-volume practices for answers. “I asked them if they had this happen, how many times, what caused it, and what they did about it,” he said. “I wanted to see if there was an underlying factor so we could implement process improvement. I also wanted to glean if there was a detrimental effect on the patient.”
Dr. Wax found that surgeons’ reasons for dropping or misplacing free flaps were very similar across the spectrum. “Every time a mistake occurred, a change was instituted to make sure that a particular circumstance didn’t arise again—and usually it didn’t happen for a while,” he said. “But over time, personnel changed, and sometimes processes we instituted changed over the course of years and the event happened again,” he added. “When asking staff about it, they admitted to being complacent about following guidelines.” In such instances, Dr. Wax would advise addressing issues and establishing a better protocol. Interestingly, Dr. Wax was pleased to learn that misplacing free flaps is a rare event, and when it does happen, it is not detrimental to the patient, because misplaced free flaps can still be used once they are cleaned.