I want to preface this story by stating that Sarah has given written authorization to share her story, allowing my colleague and me to transform a challenging experience into a valuable lesson in the inevitability of mistakes and the profound capacity for forgiveness and growth.
Ten years ago, I was approached by a distressed physician and colleague who had unintentionally harmed a patient during the course of an elective colon operation. The surgery had been two days prior, and the patient, Sarah, lay near death in the surgical intensive care unit from septic shock due to a missed bowel injury.
Sarah was a successful 46-year-old florist with a caring husband named Frank. What was supposed to have been a two-day hospital stay became a prolonged hospitalization with numerous complications and several additional surgeries. Needless to say, Sarah had a long, challenging road to recovery.
I tried to comfort my colleague as best I could. I knew it was an honest mistake and that he had performed hundreds of similar surgeries before without incident. Still, he agonized over how he could have prevented this situation, worrying about how he would be judged by his peers and, not least, what he would say to Sarah’s husband Frank.
It was a challenging time for the couple, and I knew my colleague identified and empathized with their struggle. At the same time, he was grappling with overwhelming feelings of guilt and shame, experiencing what we later understood as being the ‘second victim’ of a medical error. In the aftermath of such incidents, the spotlight naturally turns to the patient, but what often goes unnoticed is the profound impact on the clinicians involved.
Contrary to the perception often maintained by a rigid medical culture, surgical errors are an intrinsic aspect of being human. When these inevitable mistakes occur, health care professionals grapple with the overwhelming burden of responsibility, often disinclined to be vulnerable or to show signs of weakness in an environment that expects perfection. Providers can find themselves grappling with an array of emotional challenges, from burnout, post-traumatic stress, substance abuse, and even suicidal ideation.
As my colleague later recounted to me, his conversation with Frank did not go as planned. Prepared for anger and rebuke, the surgeon explained the details of the missed injury and the reason behind Sarah’s grave condition. The physician apologized and explained that he would do everything possible to regain Sarah’s quality of life. Unexpectedly, Frank reached over and consoled him. He said, “I can tell that this is really bothering you, Doc, and I want you to know that you have my utmost trust, and I know you will do everything possible for Sarah.” My colleague said it was like a weight lifted off his shoulders. He didn’t realize how burdened he was or how badly he needed to hear those words.
My colleague and I were both fortunate to be operating within a “Just Culture.” Within such a culture, accountability becomes a collective responsibility, fostering an environment free from blame where individuals can openly acknowledge their mistakes. This approach is crucial for learning and implementing preventative measures to enhance patient safety and rebuild trust. But it’s also crucial for provider safety and sending a powerful message that mistakes are viewed not as personal failures but as opportunities for system improvement.
Nevertheless, it’s increasingly difficult to maintain a just culture, especially in cases like that of RaDonda Vaught, a health care provider in Tennessee who was charged with homicide following an unintended medication error. Providers now are not only hesitant to show weakness but fearful of the potential consequences and legal repercussions. This atmosphere of fear fosters a culture of secrecy and hinders open communication that is essential for learning, improvement, and humanism in health care.
Medical errors do happen. While they can be devastating, how we respond to those errors is what makes us human. Offering a sincere apology in the proper context and expressing empathy, trust, and compassion can go a long way toward mitigating the shocking impact. To protect providers, 39 states have “I’m Sorry” laws in which providing an apology, showing sympathy, or benevolence is not admissible as evidence of an admission of liability for medical malpractice.
In the aftermath of a medical error, providers need to realize they’re not alone. I’m thankful my colleague reached out to me so I could offer support and normalize the fact that mistakes happen. Even for those not willing to share, services like the Physician Support Line at (888) 409-0141 can provide invaluable guidance and understanding for health care providers in need. For a more proactive approach, I believe leaders should promote physician well-being by utilizing some of the toolkits and playbooks offered by the American Medical Association.
One hundred thirty-six days later, after numerous post-operative complications and four surgeries to repair the injury and an abdominal wall fistula, Sarah left the hospital. For both my colleague and I, this experience brightened the path toward a more compassionate health care culture. If Sarah and Frank could find the grace to understand and forgive, then surely, our broader health care community can embrace the shared humanity that unites us all, complete with imperfections, vulnerabilities, and the capacity for healing and growth.
Scott Ellner has been a general surgeon for over 20 years, and can be reached at PEAK Health. He has transitioned into health care executive roles due to his passion for patient safety, quality, and value-based care delivery. His authentic leadership style inspires team members to navigate challenging situations, such as resistance to change and innovation, in order to bring about meaningful transformation. Most recently, he served as the CEO of Billings Clinic, the largest health system in Montana. During his tenure, Forbes recognized the clinic as the best place to work in the state. It was also at that time that he formulated a strategic growth plan that included the development of a level 1 trauma network and a rural-based clinically integrated network.