LAUSR

There are two viewpoints on medical errors: one that focuses on the person, the other that focuses on the system. James Reason taught us to reject the person viewpoint, which focuses on the errors and violations of individual people. The focus on the person leads us to direct remedial efforts at people on the front line of patient care. It also justifies blaming the individual who errs. Instead, Reason helped us don system lenses and pull back to accommodate a system viewpoint that traces causal factors back to the system as a whole. This approach persuades us to direct remedial effort at situations and organisations. The system viewpoint exposes individual blame as myopic and unjust, and unlikely to lead to improvements in safety. As part of the system, individual people make mistakes, and share responsibility for failures and patient harm. But it is not all their fault when things go wrong. Institutions today should be aware that humans will err and create failsafes to defend against this. As Reason wrote, ‘we cannot change the human condition, but we can change the conditions under which humans work.’ Despite this understanding, the greatest trauma for individual clinicians is making an error that harms a patient. Clinicians suffer emotional trauma after adverse events, with a cascade of anxiety, sadness, guilt, anger and frustration. They worry about the patient, about damage to their own reputation and potential punishment. Importantly, they feel like it is all their fault, like they have failed, that they are incompetent. They feel isolated and pinned down in the spotlight. It is a terrible place to be. This is the paradox that surrounds the understanding and impact of medical error for clinicians. Although we now understand that it is the system that creates patient safety and adverse events, when there is an adverse event, we feel intensely that we are to blame. There may be a physiological mechanism behind this, as the acute stress reaction that accompanies traumatic event can cloud the ability to think rationally. The feeling is exacerbated by the culture of blame that persists in healthcare, and that is pervasive in society as a whole. The term ‘second victim’ was introduced to describe the experience of clinicians who are traumatised by making an error that harms a patient. The same flaws in the system that harm the patient can also harm clinicians who are also tripped up by those system factors. The term ‘second victim’ has provoked some controversy. Some are unhappy about this term, particularly patients who have been harmed and mistreated by healthcare providers. However, there has been no satisfactory replacement, and the term has come into common use worldwide. 6 The second victim phenomenon has been studied most intensively in Commonwealth countries, but has been found in settings around the world. In their EMJ paper, Yan and colleagues present the first data on the second victim experience among emergency medicine physicians in China. In this large study, more than two out of five physicians reported making a major medical error during the last 3 months. Physicians were more likely to report making a medical error when they also reported short staffing, verbal aggression in the workplace and intense work stress. Over threequarters of all respondents reported effortreward imbalance and personal depressive symptoms. Medical errors were significantly associated with negative affect and lower selfefficacy. The factors that were associated with selfreported medical errors are supported by previous research. These include a shortage of providers, and increased workload and fatigue, both of which are likely to be interrelated. Workplace aggression may also be related to these factors and has been associated with clinician burnout. The authors obtained over 10 000 responses to their survey. However, although 68% of licensed emergency physicians who clicked on their survey link completed the survey, this is not a true response rate as the size of the denominator is unknown. There was also a remarkably high rate of poor physical health among respondents, with over 36% selfreporting ‘bad’ physical health. Thus, we do not know if their sample is truly representative of all licensed emergency physicians in China. Elements of the study design could have been improved. For example, the primary outcome of the study regarding selfreported medical error was: ‘Are you concerned that you have made any major medical errors in the last three months?’ This item is doublebarrelled, that is, asking about two potentially independent concepts: concern and having made a medical error. In addition, the definition of ‘major error’ is unclear. These issues could potentially reduce the reliability of responses. There was also a suggestion that there may have been a degree of reporting bias in responses to the question. Female gender, lower educational level and working in a community hospital were associated with not reporting having made errors. These physician types may be more socially vulnerable, and thus less likely to report medical errors. The assurances of anonymity on the survey may have been unconvincing. Despite these limitations, this study documents that physicians working in EDs across China believe that they commonly make medical errors. They find these incidents to be highly distressing. The study appears to be the first to explore the second victim experience among clinicians in China. The study also confirms the vicious circle of negative emotions of clinicians and the risk for medical errors. When things go wrong, clinicians become more aware of their fallibility, and feel less competent and less efficacious. Their selfesteem shrinks, and their mood drops. They may be more likely to second guess the decisions they make in caring for patients, and to rely less on the reflexes that they have acquired in their training. All of this may make them more likely to err again. How do we lessen the trauma for clinicians when they inevitably make errors in caring for patients? In addition to teaching them to see the system, how can we also get them to feel with system lenses? We agree with the authors that understanding and accounting for distress among clinicians is a prerequisite to improving their mental health and wellbeing. Doing Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA Emergency Medicine, Queen’s Medical Center, Honolulu, Hawaii, USA