Veterinarians' experiences with near misses and adverse events

Lori R. Kogan Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO 80523.

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Mark Rishniw Veterinary Information Network, 777 W Covell Blvd, Davis, CA 95616.

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Peter W. Hellyer Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO 80523.

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Regina M. Schoenfeld-Tacher Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607.

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Abstract

OBJECTIVE To assess the prevalence of medical errors (specifically, near misses [NMs] and adverse events [AEs]) and their personal and professional impact on veterinarians.

DESIGN Cross-sectional study.

SAMPLE Members of the Veterinary Information Network (n = 46,481).

PROCEDURES An electronic survey regarding veterinarians' experiences with NMs and AEs was distributed via email to an online veterinary community between September 24 and October 21, 2015. Responses were summarized and compared between genders by means of the χ2 test.

RESULTS 606 veterinarians completed the survey (1.3% response rate). Overall, 447 (73.8%) respondents reported involvement in ≥ 1 NM (n = 389 [64.2%]) or AE (179 [29.5%]). The NMs had a short-term (≤ 1 week) adverse impact on professional life for 68.0% (261/384) of respondents and longer-term negative impact for 36.4% (140/385). The impact on respondents' personal lives was similar (63.6% [245/385] and 33.5% [129/385], respectively). For AEs, these numbers were 84.1% (148/176), 56.2% (99/177), 77.8% (137/176), and 50.6% (89/175), respectively. Both NMs and AEs were more likely to negatively impact female veterinarians than male veterinarians.

CONCLUSIONS AND CLINICAL RELEVANCE These findings suggested that many veterinarians experience emotional distress after a medical error. Support should be provided to mitigate this adverse impact on the wellbeing of veterinarians and, potentially, their future patients.

Abstract

OBJECTIVE To assess the prevalence of medical errors (specifically, near misses [NMs] and adverse events [AEs]) and their personal and professional impact on veterinarians.

DESIGN Cross-sectional study.

SAMPLE Members of the Veterinary Information Network (n = 46,481).

PROCEDURES An electronic survey regarding veterinarians' experiences with NMs and AEs was distributed via email to an online veterinary community between September 24 and October 21, 2015. Responses were summarized and compared between genders by means of the χ2 test.

RESULTS 606 veterinarians completed the survey (1.3% response rate). Overall, 447 (73.8%) respondents reported involvement in ≥ 1 NM (n = 389 [64.2%]) or AE (179 [29.5%]). The NMs had a short-term (≤ 1 week) adverse impact on professional life for 68.0% (261/384) of respondents and longer-term negative impact for 36.4% (140/385). The impact on respondents' personal lives was similar (63.6% [245/385] and 33.5% [129/385], respectively). For AEs, these numbers were 84.1% (148/176), 56.2% (99/177), 77.8% (137/176), and 50.6% (89/175), respectively. Both NMs and AEs were more likely to negatively impact female veterinarians than male veterinarians.

CONCLUSIONS AND CLINICAL RELEVANCE These findings suggested that many veterinarians experience emotional distress after a medical error. Support should be provided to mitigate this adverse impact on the wellbeing of veterinarians and, potentially, their future patients.

Adverse events and medical errors in veterinary and human medicine are inevitable, and research has only just begun to shed light on the prevalence of these incidents.1 Medical errors can include those involving medications (eg, wrong medication, wrong dose, or failure to recognize an allergy), misidentification of patients, and errors or delays in diagnosis. Surgical errors (eg, wrong surgical site or procedure) are also possible, as are judgment errors that lead to an unnecessary surgery or delay of a necessary operation.2

A medical error can be defined as “a commission or omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were any negative consequences.”3 Such errors can therefore be distinguished from complications or unpreventable AEs, which are an acknowledged risk of medical care and surgical procedures.4,5 This definition of medical error also includes actions that do not actually result in direct harm to patients, referred to as NMs.5,6 An NM can be defined as an incident that could have had adverse consequences but did not, and is indistinguishable from a full-fledged AE in all but outcome. Examples of NMs include incorrect selection of a potentially harmful drug that was never administered, prescription of the wrong drug that resulted in no harm to the patient, or scheduling of surgery for the wrong body part but catching this error before surgery begins.

The effect of these errors on patient outcomes is staggering. Findings in a 2016 study1 suggest that 251,454 patient deaths/y in US hospitals are attributable to medical error. Although much research has been conducted to explore the impact of medical errors on patient outcome, the impact of these errors on physicians has received much less attention in the literature.3,7–9 However, data are emerging regarding the impact of these errors on the health-care providers and on patients treated by providers involved in an error.10

Health-care providers involved in an AE or NM can be considered secondary victims, defined as those who are involved in an unanticipated adverse patient event, medical error, or patient-related injury and are traumatized or negatively impacted by the incident.11 Such health-care providers can consequently experience shame, guilt, anger, self-doubt, fear, anxiety, grief and depression, withdrawal or agitation, impaired concentration, and poor memory and can reexperience the incident itself.7,12–14 Physicians have also reported adverse impacts on their job satisfaction, ability to sleep, relationships with colleagues, and self-worth.7,14 These effects can be short or long term and can sometimes result in considerable functional impairment.9,11,14 In a recent study,15 approximately one-third of physicians reporting an AE or NM in the United States and United Kingdom indicated feeling that their work performance or personal life had suffered.15 It has been suggested that physicians who become distressed after an error are at an increased risk of making medical errors in the future.16–18

Although medical errors, including AEs and NMs, represent an important area of study within medicine, no studies have been reported regarding the impact of such errors on veterinarians. To assess this issue and help guide the creation of programs to support veterinarians following medical errors, an understanding is needed of the impact these incidents have on veterinarians. Therefore, the purpose of the study reported here was to survey veterinarians to determine the impact of AEs and NMs on their well-being as well as their experiences regarding decisions to disclose these errors and their perceived availability of support.

Materials and Methods

Survey development

In collaboration with the administrators of the online veterinary community VIN, an anonymous online survey was created to evaluate veterinarians' perceptions about their experiences with medical errors, ranging from AEs to NMs, and the decisions associated with disclosing those errors. The survey was modeled after a questionnaire administered to physicians in another study,19 in which respondents who reported being involved with an NM or AE were asked how it affected several aspects of their job satisfaction, psychological well-being, and physiologic reactions. It was designed by the authors (veterinarians and social scientists) and pilot tested on a sample of veterinarians. Three academic veterinarians (colleagues of the authors) and 2 veterinarians in private practice assessed face validity of the survey. Their feedback was used to further refine the survey questions and shorten the overall length of the survey.

Survey distribution

Invitations to complete the online survey (Supplementary Appendix S1, available at avmajournals.avma.org/doi/suppl/10.2460/javma.252.5.586), which was made available through the VIN website,a were distributed to all VIN members in 2 emails, sent 2 weeks apart beginning September 24, 2015, with a response deadline of October 21, 2015. This study was reviewed and approved by the Institutional Review Board at Colorado State University.

Survey content

Respondents were initially asked to indicate whether they had ever been personally involved with an NM or AE in the past 12 months. Definitions of NMs and AEs based on slight modifications of the World Alliance definition20 were provided for respondents to use when answering the questions. An AE was defined in the survey as “something that goes wrong that results in some degree of patient harm (e.g., wrong surgery site, drug overdose, anesthetic complication).” An NM was defined in the survey as a “‘bullet dodged’, i.e. an event that could have had adverse consequences but did not.” Further examples were given to support the distinction between AEs and NMs previously described in this report. No definition was provided for “involved,” leaving interpretation open to respondents, because the authors believed that a veterinarian could be impacted by an AE or NM, whether they personally made the error or were involved in trying to correct the problem after a colleague or staff member made the error. Branching logic was then used to present questions pertaining to the type or types of errors reported by respondents. If any AEs were reported, questions about those AEs were presented first, followed by a similar series of questions for NMs.

Respondents were asked to quantify the amount of AEs causing serious patient harm and minor patient harm they had experienced during the year immediately preceding the survey. Similar data were gathered for NMs. The subsequent survey sections explored the potential impact of an AE or NM on respondents' personal and professional lives. Participants were asked to indicate the degree to which they had been affected.

In the next section, respondents were asked to rate the severity with which they had experienced various emotions and psychological symptoms as a result of the most severe NM or AE they had been involved with in the prior 12 months. The response options for this question ranged from strongly disagree to strongly agree. Respondents were next asked to indicate whether they had discussed the NM or AE (as appropriate) with other people. If they answered affirmatively, the next set of questions inquired about whether they had spoken with a supervisor, a client, or someone else as well as the outcomes of this disclosure. Multiple response options were provided, spanning the range from colleagues to family and health-care providers. Participants were able to select as many choices as applicable, and they could also enter free-text responses for the category “other.”

The sections that followed probed respondents for their reasons for disclosing or not disclosing the AE or NM to colleagues and clients and the result of these disclosures. Further questions inquired about their satisfaction with their disclosure and potential repercussions encountered in the workplace.

The last set of questions was presented identically to all respondents. These questions addressed whether respondents had been involved with any incidents (NMs or AEs) that should have been reported, but were not. Two open-ended questions on coping strategies and support systems were also included, providing an opportunity for respondents to list what had been helpful to them and what else could be offered in the future. In recognition of the association between stress at work and at home, respondents were asked where they felt negative or stressful incidents in their life outside of work in the past 12 months had impacted the number of NMs or AEs they experienced at work during this period. A separate question investigated whether participants' experiences with NMs or AEs at work in the past 12 months had impacted their perceived stress outside of work. Respondents were also asked to indicate whether the number of NMs or AEs they experienced at work impacted the amount or degree of negative or stressful incidents in their professional and personal lives. They were asked to report their feelings about going to work on most days (response options ranged from extreme dread to very excited) as well as how they would adjust the number of hours they would work if they had an ideal job (decrease, increase, or remain the same).

Finally, respondents were asked to provide demographic information, such as current practice setting (academia, private practice, nonclinical position, or not currently practicing), age (20s, 30s, 40s, 50s, 60s, or ≥ 70 years), years in practice (< 2, 2 to 5, 6 to 10, or > 10), and gender.

Statistical analysis

Descriptive statistics were calculated by use of commercially available software.b The χ2 test was used to examine differences in response distributions between males and females or between NMs and AEs. Values of P < 0.05 were considered significant.

Results

Respondents

Invitations to participate in the online survey were distributed to 46,481 VIN members. No data were available on the number of invitations that could not be delivered owing to a change in email address or the number of emails that went unread by addressees. A total of 606 veterinarians completed the survey, representing a 1.3% response rate.

Of respondents who reported their gender (n = 557), 431 (77.4%) were female and 126 (22.6%) were male. Of respondents who reported how long they had been in practice (n = 561), 51 (9.1%) indicated < 2 years, 88 (15.7%) indicated 2 to 5 years, 77 (13.7%) indicated 6 to 10 years, and 339 (60.4%) indicated > 10 years; 6 [1.1%] respondents indicated that this question was not applicable. Most respondents (503/561 [89.7%]) reported that they were currently working in private practice. A small number reported working in academia (27/561 [4.8%]) or nonclinical positions (22/561 [3.9%]) or were not currently practicing (9/561 [1.6%]). Of respondents who reported their age (n = 556), 63 (11.3%) were in their 20s, 146 (26.3%) were in their 30s, 132 (23.7%) were in their 40s, 139 (25.0%) were in their 50s, 65 (11.7%) were in their 60s, and 11 (2.0%) were ≥ 70 years of age.

Prevalence of NMs and AEs

Overall, almost three-quarters of respondents (447/606 [73.8%]) indicated they had been involved in ≥ 1 NM (n = 389 [64.2%]) or AE (179 [29.5%]) in the past 12 months. No significant differences in frequencies of reporting AEs or NMs were identified on the basis of respondent demographic groupings (age, current position, or years in practice).

Respondents who reported involvement in any NM or AE during the past 12 months were asked about the potential for harm (ie, severity) involved in these errors; 385 responded to the question of involvement in an NM with the potential to cause minor harm to the patient. Within this group, 47 (12.2%) indicated they had not been involved in any NM incident with potential for minor harm, 138 (35.8%) reported involvement in 1 incident, 99 (25.7%) reported involvement in 2 incidents, 32 (8.3%) reported involvement in 3 incidents, 20 (5.2%) reported involvement in 4 incidents, 22 (5.7%) reported involvement in 5 incidents, and 27 (7.0%) reported involvement in > 5 incidents. When asked about involvement in NMs with the potential for serious harm to a patient, 128 of 386 (33.2%) respondents reported no involvement with this type of incident, 170 (44.0%) reported involvement in 1 incident, 50 (13.0%) reported involvement in 2 incidents, 17 (4.4%) reported involvement in 3 incidents, and 21 (5.5%) reported involvement in ≥ 3 incidents.

Regarding AE incidents with the potential for minor patient harm, 57 of 173 (32.9%) respondents stated no personal involvement, 73 (42.2%) reported involvement in 1 incident, 25 (14.5%) reported involvement in 2 incidents, 8 (4.6%) reported involvement in 3 incidents, and 12 (6.9%) reported involvement in ≥ 3 incidents. For AEs with the potential to cause serious patient harm, 66 of 176 (37.5%) respondents stated they had never been personally involved, 88 (50.0%) reported involvement in 1 incident, 18 (10.2%) reported involvement in 2 incidents, and 4 (2.3%) reported involvement in ≥ 2 incidents.

Impact of the most severe NM or AE in the past 12 months

In response to questions regarding the impact of NMs on their professional life, 261 of 384 (68.0%) respondents reported a short-term (≤ 1 week after the incident) negative impact and 140 of 385 (36.4%) reported a long-term (> 1 week after the incident) negative impact. For AEs, these numbers were 148 of 176 (84.1%) and 99 (56.2%), respectively. In response to questions regarding the impact of NMs on their personal life, 245 (63.8%) reported a short-term negative impact and 129 (33.5%) reported a longer term negative impact. For AEs, these numbers were 137 (77.8%) and 89 (50.6%), respectively.

A significantly greater proportion of females than males reported a short-term (P = 0.03) and long-term (P = 0.01) negative impact of NMs on their personal life (Table 1). Similar gender differences were also identified for AEs with respect to short-term negative impact on professional life (P = 0.006), long-term negative impact on professional life (P = 0.01), and long-term negative impact on personal life (P = 0.003).

Table 1—

Comparisons of responses by gender to an online survey completed by veterinarian VIN members regarding the impact of the most severe NM or AE they had been personally involved in during the past 12 months.

Variable, by genderExtremely negativeModerately negativeMinimally negativeNo impactP value
Short-term impact of NM on personal life0.03
  Female (n = 263)35 (13.3)69 (26.2)64 (24.3)95 (36.1)
  Male (n = 75)3 (4.0)14 (18.7)26 (34.7)32 (42.7)
Short-term impact of AE on personal life0.06
  Female (n = 142)47 (33.1)35 (24.6)33 (23.2)27 (19.0)
  Male (n = 30)4 (13.3)6 (20.0)9 (30.0)11 (36.7)
Long-term impact of NM on personal life0.01
  Female (n = 263)6 (2.3)32 (12.2)56 (21.3)169 (64.3)
  Male (n = 75)0 (0)5 (6.7)7 (9.3)63 (84.0)
Long-term impact of AE on personal life0.003
  Female (n = 141)9 (6.4)27 (19.1)44 (31.2)61 (43.3)
  Male (n = 30)0 (0)3 (10.0)3 (10.0)24 (80.0)
Short-term impact of NM on professional life0.79
  Female (n = 263)27 (10.3)74 (28.1)77 (29.3)85 (32.3)
  Male (n = 74)6 (8.1)21 (28.4)19 (25.7)28 (37.8)
Short-term impact of AE on professional life0.006
  Female (n = 142)40 (28.2)58 (40.8)25 (17.6)19 (13.4)
  Male (n = 30)2 (6.7)9 (30.0)11 (36.7)8 (26.7)
Long-term impact of NM on professional life0.07
  Female (n = 263)3 (1.1)34 (12.9)59 (22.4)167 (63.5)
  Male (n = 75)0 (0)8 (10.7)8 (10.7)59 (78.7)
Long-term impact of AE on professional life0.01
  Female (n = 143)12 (8.4)40 (28.0)35 (24.5)56 (39.2)
  Male (n = 30)0 (0)4 (13.3)5 (16.7)21 (70.0)

Data are reported as number (%). Short term was defined as ≤ 1 week after the event. Long term was defined as > 1 week after the event. Of the 606 respondents, 447 reported involvement in at least 1 NM, and 179 reported involvement in at least 1 AE.

Following the most severe NM with which they had been involved, 138 of 367 (37.6%) respondents of both genders reported having less confidence in their ability as a doctor, 115 of 365 (31.5%) felt their confidence in their abilities had suffered, 109 of 369 (29.5%) agreed they felt less satisfied with their job, and 97 of 366 (26.5%) felt burned out. Many of these respondents also reported feeling grateful that the NM was caught (333/367 [90.7%]) and determined to improve (311/366 [85.0%]). Significantly greater proportions of females than males reported agreement with statements regarding less confidence as a doctor (P = 0.03), questioning their career choice (P = 0.01), overall decrease in happiness (P = 0.02), feeling persistently guilty (P = 0.003), feeling burned out (P = 0.02), having difficulties concentrating or focusing (P = 0.04), and feeling their confidence in their abilities had suffered (P = 0.02; Table 2).

Table 2—

Significant (P < 0.05) comparisons of responses by gender to an online survey completed by veterinarian VIN members regarding the emotional impact of the most severe NM or AE respondents had been personally involved in during the past 12 months.

Question, by genderDisagreeNeutralAgree
I have less confidence in my ability as a doctor as a result of the NM
  Female (n = 263)113 (43.0)42 (16.0)108 (41.1)
  Male (n = 75)44 (58.7)12 (16.0)19 (25.3)
I have less confidence in my ability as a doctor as a result of the AE
  Female (n = 142)57 (40.1)17 (12.0)68 (47.9)
  Male (n = 30)14 (46.7)8 (26.7)8 (26.7)
I have begun questioning my career choice as a result of the NM
  Female (n = 264)153 (58.0)57 (21.6)54 (20.5)
  Male (n = 75)57 (76.0)12 (16.0)6 (8.0)
My overall happiness has decreased as a result of the NM
  Female (n = 265)135 (50.9)69 (26.0)61 (23.0)
  Male (n = 75)52 (69.3)14 (18.7)9 (12.0)
My overall happiness has decreased as a result of the AE
  Female (n = 142)50 (35.2)37 (26.1)55 (38.7)
  Male (n = 30)18 (60.0)4 (13.3)8 (26.7)
I feel persistently guilty as a result of the NM
  Female (n = 265)143 (54.0)55 (20.8)67 (25.3)
  Male (n = 74)56 (75.7)9 (12.2)9 (12.2)
I feel burned out as a result of the NM
  Female (n = 262)138 (52.7)50 (19.1)74 (28.2)
  Male (n = 75)53 (70.7)11 (14.7)11 (14.7)
I am having difficulties concentrating and/or focusing as a result of the NM
  Female (n = 263)170 (64.6)59 (22.4)34 (12.9)
  Male (n = 74)58 (78.4)13 (17.6)3 (4.1)
I feel my confidence in my abilities has suffered as a result of the NM
  Female (n = 262)127 (48.5)45 (17.2)90 (34.4)
  Male (n = 74)47 (63.5)14 (18.9)13 (17.6)

See Table 1 for key.

Following the most severe AE with which they had been involved, 78 of 176 (44.3%) respondents of both genders agreed they felt less confident in their ability as a doctor, 78 of 176 (44.3%) felt their confidence in their abilities had suffered, 75 of 177 (42.4%) felt less satisfied with their job, 66 of 175 (37.7%) felt burned out, 65 of 176 (36.9%) had a decrease in overall happiness, 61 of 174 (35.1%) felt that their professional reputation had been negatively impacted, 58 of 172 (33.7%) had problems sleeping, and 59 of 176 (33.5%) felt persistently guilty. However, 149 of 175 (85.1%) respondents also felt determined to improve. Significantly greater proportions of females than males reported agreement with statements regarding feeling less confidence as a doctor (P = 0.04) and an overall decrease in happiness (P = 0.04; Table 2).

Disclosure of NMs or AEs

Most respondents who reported personal involvement in an NM or AE in the past 12 months indicated that they had discussed that NM (306/370 [82.7%]) or AE (164/178 [92.1%]) with someone. The persons to whom respondents most commonly disclosed these incidents were their colleagues (peers and seniors) and family or friends (Table 3).

Table 3—

Number (%) of respondents in Table 1 who reported disclosure of an NM or AE to various persons.

PersonNM (n = 389)AE (n = 179)
Colleague (peer)224 (57.6)133 (74.3)
Colleague (senior)93 (23.9)74 (41.3)
Colleague (other profession)38 (9.8)17 (9.5)
Family or friends162 (41.6)99 (55.3)
Manager44 (11.3)40 (22.3)
Mentor16 (4.1)14 (7.8)
Therapist or counselor13 (3.3)6 (3.4)
Staff, employees, or technicians27 (6.9)17 (9.5)
My health-care provider2 (0.5)2 (1.1)

Note that respondents were allowed to select > 1 response option.

Disclosure to supervisor—Among respondents reporting personal involvement in an NM who had a supervisor (n = 207), 136 (65.7%) reported telling their supervisor about the incident. Among respondents reporting personal involvement in an AE who had a supervisor (n = 100), 81 (81.0%) reported telling their supervisor. The most common reason reported for telling a supervisor (for NMs and AEs) was that it was the ethically correct thing to do (Table 4). For NMs, the next most common reasons were desires to foster trust in their supervisor and set a good example for colleagues. For AEs, the next most common reasons were desires to preempt potential legal ramifications and foster trust in their supervisor. For both NMs and AEs, most respondents reported feeling satisfied with the results of disclosing the incident to their supervisor (Table 5).

Table 4—

Number (%) of respondents in Table 1 who reported various reasons for disclosure of an NM or AE to their supervisor.

ReasonNM (n = 131)AE (n = 81)
I felt it was ethically correct115 (87.8)68 (84.0)
I wanted to foster my supervisor's trust in me53 (40.5)27 (33.3)
I was trying to set good example for colleagues41 (31.3)22 (27.2)
It is our clinic policy30 (22.9)19 (23.5)
I thought the supervisor would find out anyway23 (17.6)25 (30.9)
I wanted to preempt potential legal ramifications26 (19.8)28 (34.6)
Felt guilty27 (20.6)16 (19.8)
Other15 (11.5)9 (11.1)

Note that respondents were allowed to select > 1 reason.

Table 5—

Number (%) of respondents in Table 1 who reported various levels of satisfaction with the results of their disclosure of an NM (n = 134) or AE (81) to their supervisor.

EventVery dissatisfiedDissatisfiedNeutralSatisfiedVery satisfied
NM5 (3.7)6 (4.5)23 (17.2)67 (50.0)33 (24.6)
AE6 (7.4)9 (11.1)17 (21.0)32 (39.5)17 (21.0)

When asked about their experiences after reporting an NM, 58 of 131 (44.3%) respondents reported feeling embarrassed (to a great deal or moderate amount), 29 (22.1%) felt blamed, 13 (9.9%) received closer supervision, 3 (2.3%) had responsibilities removed, and 1 (0.8%) received disciplinary action (Table 6). In terms of outcomes of these disclosures, 79 of 131 (60.3%) respondents reported receiving empathy from colleagues, 69 (53.5% [n = 129 for this response only]) received empathy from their supervisor, 61 (46.5%) received useful feedback or advice, 55 (42.0%) had a resultant system change, and 7 (5.3%) received more training.

Table 6—

Number (%) of respondents in Table 1 who reported various effects of reporting an NM or AE.

Outcome, by error typeA great dealModerate amountMinimal amountNot at all
Being or feeling blamed
  NM (n = 131)11 (8.4)18 (13.7)37 (28.2)65 (49.6)
  AE (n = 80)11 (13.8)20 (25.0)20 (25.0)29 (36.3)
A system change was implemented
  NM (n = 131)11 (8.4)44 (33.6)37 (28.2)39 (29.8)
  AE (n = 80)12 (15.0)19 (23.8)21 (26.3)28 (35.0)
Useful feedback or advice
  NM (n = 131)18 (13.7)43 (32.8)39 (29.8)31 (23.7)
  AE (n = 80)12 (15.0)21 (26.2)25 (31.3)22 (27.5)
Empathy from colleague
  NM (n = 131)31 (23.7)48 (36.6)29 (22.1)23 (17.6)
  AE (n = 79)21 (26.6)30 (38.0)21 (26.6)7 (8.9)
Empathy from supervisor
  NM (n = 129)24 (18.6)45 (34.9)33 (25.6)27 (20.9)
  AE (n = 80)17 (21.3)27 (33.8)19 (23.8)17 (21.3)
Closer supervision
  NM (n = 131)1 (0.8)12 (9.2)24 (18.3)94 (71.8)
  AE (n = 81)4 (4.9)5 (6.2)14 (17.3)58 (71.6)
Responsibilities removed
  NM (n = 131)2 (1.5)1 (0.8)5 (3.8)123 (93.9)
  AE (n = 81)1 (1.2)5 (6.2)0 (0)75 (92.6)
Given more training
  NM (n = 131)2 (1.5)5 (3.8)14 (10.7)110 (84.0)
  AE (n = 81)1 (1.2)3 (3.7)10 (12.3)67 (82.7)
Disciplinary action
  NM (n = 131)0 (0)1 (0.8)3 (2.3)127 (96.9)
  AE (n = 81)1 (1.2)2 (2.5)1 (1.2)77 (95.1)
Feeling embarrassed
  NM (n = 131)21 (16.0)37 (28.2)34 (26.0)39 (29.8)
  AE (n = 81)22 (27.2)21 (25.9)18 (22.2)20 (24.7)

When asked about their experiences after reporting an AE, 43 of 81 (53.1%) respondents reported feeling embarrassed, 31 of 80 (38.8%) felt blamed, 9 of 81 (11.1%) received closer supervision, 3 of 81 (3.7%) had responsibilities removed, and 3 of 81 (3.7%) received disciplinary action (Table 6). Fifty-one of 79 (64.6%) respondents reported receiving empathy from colleagues, 34 of 80 (55.0%) received empathy from their supervisor, 33 of 80 (41.2%) received useful feedback or advice, 31 of 80 (38.8%) had a resultant system change, and 4 of 81 (4.9%) received more training.

When asked whether there were any NMs that they did not report to a supervisor, 27 of 131 (20.6%) respondents indicated yes. For AEs, these numbers were 2 of 81 (2.5%). Some respondents did not answer the initial question yet indicated a reason for not disclosing in the follow-up question. The most common reasons given for not disclosing an NM to a supervisor were wanting to avoid needlessly upsetting their supervisor, lack of an appropriate opportunity, fear of losing their supervisor's respect or trust, and other (Table 7). The most common reason provided in the “other” category was that there was no need to report anything given that nothing had actually happened. The most common reasons given for not disclosing an AE to a supervisor were a dislike of confrontation, wanting to avoid needlessly upsetting their supervisor, and other. The most common reasons provided in the “other” category included that their supervisor already knew about the AE, they did not feel it was necessary, and that the situation had been resolved.

Table 7—

Number (%) of respondents in Table 1 who reported various reasons for failing to disclose an NM or AE to their supervisor.

ReasonNM (n = 93)AE (n = 20)
I was afraid my supervisor would be upset or angry7 (7.5)5 (25)
I was afraid of legal ramifications2 (2.2)0 (0)
Colleagues discouraged it0 (0)1 (5)
I was afraid of damaging my relationship with my supervisor11 (11.8)2 (10)
I was afraid of losing my supervisor's respect or trust18 (19.4)1 (5)
I did not know how to express it7 (7.5)5 (25)
I do not like confrontation10 (10.8)6 (30)
I did not feel there was an appropriate opportunity21 (22.6)4 (20)
I did not want to needlessly upset my supervisor31 (33.3)6 (30)
Other39 (41.9)7 (35)

Disclosure to clients—When asked whether they had reported any NMs to clients in the last 12 months, 147 of 368 (39.9%) respondents replied yes. For AEs, these numbers were 137 of 178 (77.0%). The most common reasons given for disclosing an NM to a client were feeling that it was the ethically correct thing to do, wanting to foster the client's trust, and wanting to set good example for colleagues (Table 8). For AEs, the top reasons were that it was the ethically correct thing to do, wanting to foster the client's trust, and that it was the clinic policy (33, 24.5%). When asked how satisfied they were with the disclosure to their clients about the NM or AE, 105 of 145 (72.4%) and 78 of 137 (56.9%) respondents, respectively, reported satisfaction (Table 9).

Table 8—

Number (%) of respondents in Table 1 who reported various reasons for disclosure of an NM or AE to their clients.

ReasonNM (n = 145)AE (n = 136)
I felt it was ethically correct135 (93.1)124 (91.2)
I wanted to foster the client's trust in me71 (49.0)60 (44.l)
I was trying to set good example for colleagues45 (31.0)30 (22.1)
It is our clinic policy29 (20.0)33 (24.5)
I felt guilty24 (16.6)29 (21.3)
I thought the client would find out anyway19 (13.1)28 (20.6)
Table 9—

Number (%) of respondents in Table 1 who reported various levels of satisfaction with the results of their disclosure of an NM (n = 145) or AE (137) to their clients.

EventVery dissatisfiedDissatisfiedNeutralSatisfiedVery satisfied
NM3 (2.1)9 (6.2)28 (19.3)66 (45.5)39 (26.9)
AE8 (5.8)13 (9.5)38 (27.7)52 (38.0)26 (19.0)

In response to whether they had any NMs in the past 12 months that they had chosen not to report to clients, 67 of 146 (45.9%) respondents indicated yes. For AEs, these numbers were 13 of 138 (9.4%). Some respondents did not answer the initial question yet indicated a reason for not disclosing in the follow-up question. The most common reasons given for failing to disclose an NM to a client were wanting to avoid needlessly upsetting the client, fear of damaging the client-clinician relationship, and other (Table 10). Most responses in the “other” category included variations of not wanting to upset or worry the client or feeling like it was not the best choice in the situation. The most common reasons given for failing to disclose an AE to a client were wanting to avoid needlessly upsetting the client, being afraid of damaging the client-clinician relationship, and being afraid the client would be angry or upset.

Table 10—

Number (%) of respondents in Table 1 who reported various reasons for failing to disclose an NM or AE to their clients.

ReasonNM (n = 284)AE (n = 48)
I was afraid the client would be upset or angry48 (16.9)18 (37.5)
I was afraid of legal ramifications37 (13.0)11 (23.0)
Supervisor discouraged it7 (2.5)5 (10.4)
I was afraid of damaging the client-clinician relationship67 (23.6)18 (37.5)
I was afraid of losing the client24 (8.5)8 (16.7)
I did not know how to express it21 (7.4)12 (25.0)
I do not like confrontation42 (14.8)16 (33.3)
I did not feel there was an appropriate opportunity42 (14.8)12 (25.0)
I did not want to needlessly upset the client171 (60.2)26 (54.2)
Other105 (37.0)9 (20.8)

Impact of NMs and AEs on personal life

Although 284 of 404 (70.3%) participants reported that their perceived stress level outside of work had not impacted the number of NMs or AEs they had experienced during the past 12 months, 16 (4.0%) reported that high stress outside of work had markedly increased the frequency of these incidents and 97 (24.0%) reported it had slightly increased the frequency of these incidents. In response to whether NMs or AEs at work in the past year had impacted their perceived stress outside of work, 220 of 404 (54.5%) respondents replied that it had not had an impact, 46 (11.4%) indicated a marked increase in the number or degree of negative life experiences outside of work during this time, and 132 (32.7%) reported a slight increase.

Attitude toward work and work hours

When asked how they felt about going to work on most days (response options ranging from extreme dread to very excited), the largest proportions of respondents indicated feeling minimally or moderately excited. No difference was identified in these responses on the basis of whether respondents had been personally involved in an NM or AE or whether they had experienced an AE or NM that caused a severe impact. However, a significantly (P = 0.03) greater proportion of females than males reported dread and less excitement (Table 11).

Table 11—

Number (%) of respondents in Table 1 who reported various attitudes toward going to work most days, by gender.

AttitudeFemale (n = 430)Male (n = 125)
Extreme dread level or moderate dread38 (8.8)6 (4.8)
Minimal dread level74 (17.2)15 (12.0)
Minimally excited139 (32.3)34 (27.2)
Moderately or very excited179 (41.6)70 (56.0)

Response distributions for males differed significantly (P = 0.03) from response distributions for females.

When asked whether they would adjust the number of hours they work if they had their ideal job, 19 of 564 (3.4%) respondents indicated they would continue working the same amount of hours, 368 (65.2%) indicated they would decrease their hours, and 177 (31.4%) indicated they would increase the amount of time worked. No differences in response patterns were identified on the basis of gender or reported involvement in an NM or AE.

Discussion

A high proportion (73.8%) of respondents in the present study indicated they had been involved in ≥ 1 NM or AE in the past 12 months. This proportion is comparable with that of physicians reporting involvement with an NM or AE at some point in their career (83.3%).19 In a study9 involving physicians in internal medicine, pediatrics, family medicine, and surgery, 92% reported having been involved in a medical error or NM. In the present study, 62.5% of veterinarians reported personal involvement in ≥ 1 AE that caused serious patient harm during the past 12 months.

Near misses and AEs appear to have had a similar impact on the surveyed veterinarians as they do on physicians. A sizeable number of the veterinarians experienced short-term or long-term negative effects or both on their personal and professional life. More specifically, many respondents reported feeling less satisfied with their job, less confident as a doctor, less happy overall, less self-confident, and persistently guilty as well as having problems sleeping. These results are similar to those reported for physicians,19 who experience stress and anxiety, less job satisfaction, difficulty sleeping, and less professional confidence after an AE or NM. Other studies2,9 have shown that a sizable number of physicians who perceived that they had committed NMs or AEs consequently experienced job-related stress, anxiety about future errors, loss of confidence, sleeping difficulties, and a reduction in job satisfaction as well as depression and burnout. Furthermore, a study21 involving anesthesiologists showed that making errors had an impact on their anxiety level, confidence in their ability as a doctor, ability to sleep, and job satisfaction.

Given the large proportions of veterinarians reporting personal involvement in NMs or AEs in the present study and the magnitude of the associated detrimental effects, it would behoove the profession, as well as employers, to implement support structures for affected practitioners. These interventions could be modeled after the so-called second victim support program22 in human medicine. The existing physician support program encompasses 3 tiers of assistance and entails training local peers (the first tier) about the concept of second victims and how to provide basic support to physicians involved in an incident, such as inquiring whether they are okay. If additional care is needed, the second victim is referred to a local network of trained, formal peer supporters (the second tier). These supporters then provide one-on-one support and mentorship and refer the second victims to professional mental health providers when necessary. The third tier of the model then consists of trained professionals who are able to provide formal psychological services, including psychotherapy and pastoral counseling. A similar model could be implemented in veterinary medicine by training veterinary clinicians to provide immediate support to local colleagues. The second tier of the veterinary model could be developed either on the basis of in-person support or as an extension of an existing peer support program, such as the VIN program “Venting Over a Venti.” And finally, all veterinarians in need of formal mental health care should be referred to qualified professionals. At the same time, not all repercussions of an AE or NM are negative. Mirroring findings of a study19 conducted with physicians, some veterinarians in the present study reported positive effects as a result of their involvement with an NM or AE. The most commonly reported beneficial outcome was a desire to improve oneself to prevent something similar from happening again.

When asked about disclosure of an NM or AE, most veterinarians in the present study who disclosed an incident reported discussing the incident with a colleague or family or friend. Most also told their supervisors. The most commonly chosen reasons for disclosing the incident to a supervisor were the belief that it was ethically the correct thing to do, desire to foster trust with their supervisor, or desire to set a good example for their colleagues. For AEs, another common reason was to preempt potential legal ramifications. Most respondents reported feeling satisfied with the results of their disclosure. When asked more specifically, only a minority reported feeling blamed, receiving closer supervision, having responsibilities removed, or receiving disciplinary action. Additionally, approximately 50% of respondents reported that their disclosure resulted in a system change or that they received useful feedback or advice or empathy from colleagues or their supervisor.

Nearly half of veterinarians in the present study indicated that they had chosen not to disclose an NM, and the most common reasons were not wanting to needlessly upset their supervisor, not having the opportunity to report, or feeling that there was no need to report anything since nothing had actually happened. Approximately 20% indicated they had chosen to not report an AE, and the most common reasons were a dislike of confrontation or not wanting to needlessly upset their supervisor. Fear of negative ramifications was not among the top reasons for failing to disclose an NM or AE to a supervisor.

Approximately 40% of veterinarians disclosed ≥ 1 NM and 77% disclosed ≥ 1 AE to their clients, and the most common reasons were that the belief that it was the ethically correct thing to do and a desire to foster the client's trust. Most veterinarians reported feeling satisfied with the disclosure conversation with their clients (72.4% for NMs and 56.9% for AEs). These proportions are similar to those reported for physicians,9 89% of whom reported disclosure of a serious error and 54% of whom reported disclosure of a minor error to a patient in the past 12 months. Of the physicians who had ever disclosed a serious error to a patient, 85% were satisfied with how that conversation went. Of the physicians who had ever disclosed a minor error to a patient, 93% were satisfied with the conversation. Similarly, in another study,19 89% of physicians were satisfied with their disclosure of an AE or NM to patients, their families, or both.

Many veterinarians in the present study also indicated personal involvement in ≥ 1 NM (78.5%) or AE (29.4%) in the past 12 months that they failed to disclose to clients. The primary reasons for failure to disclose an NM included not wanting to needlessly upset the client or fear of damaging the client-clinician relationship. These reasons, in addition to fearing that the client would be angry or upset, were also provided for not disclosing an AE. Additional research would be helpful to determine whether these situations were in some way different from each other, such as the possibility that clients might react more negatively to disclosure of an AE than disclosure of an NM.

Clearly, the impact of NMs and AEs can be detrimental to veterinarians. This negative impact appeared to be even more pronounced for the female veterinarians who responded to this survey than for the male respondents. Several negative consequences were self-reported more often by women than men, including less confidence as a doctor, questioning their career choice, less overall happiness, feeling persistently guilty, feeling burned out, having difficulties concentrating or focusing, and feeling their confidence in their abilities had suffered. However, it remains unclear whether these gender differences reflected actual differences in distress levels or a greater willingness for female veterinarians to report their distress. Regardless, similar findings have been reported for female physicians who report NMs and AEs.9

Other research has shown that female physicians have less access to supportive role models and report higher levels of job-related stress and burnout than male physicians.9 In veterinary medicine, women report more work-related stress, anxiety, depression, and burnout than men.23–26 This observation is of particular importance, given that a recent study29 revealed a higher incidence of psychological distress, including suicidal ideation and depression, in female versus male veterinarians. One of the most commonly reported stressors in that study was demands of practice, which could be interpreted to include involvement in AEs and NMs.

A limitation of the present study was the low response rate of invited VIN members (1.3%), which limits the generalizability of the findings to the entire veterinary profession. However, the findings suggested that some veterinarians, like physicians, experience considerable emotional distress and job-related stress, including self-doubt, anxiety, and guilt, following errors that often go unaddressed.28 Given prior research showing a link between higher levels of personal distress and decreased empathy29,30 and the fact that medical errors represent an important component of personal distress and thereby loss of compassion,31 medical errors have the potential to adversely impact patient care, beyond the incidents themselves.32–34 Additional research is needed to understand the psychological impact of NMs and AEs on veterinarians. The impact of such incidents on subsequent patient care should also be explored. Given the sensitive nature of this topic, a prospective cohort study could be useful for examining changes in the mental health or wellness of practicing veterinarians over time and their potential association with NMs and AEs that the veterinarians encounter during the same period.

ABBREVIATIONS

AE

Adverse event

NM

Near miss

VIN

Veterinary Information Network

Footnotes

a.

VIN. Available at: www.vin.com. Accessed Jul 28, 2017.

b.

IBM SPSS Statistical Software, version 21, IBM Corp, Armonk, NY.

References

  • 1. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ 2016;353:i2139.

  • 2. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg 2010;251:9951000.

  • 3. Wu AW, Folkman S, McPhee SJ, et al. Do house officers learn from their mistakes? JAMA 1991;265:20892094.

  • 4. Barron WM, Kuczewski MG. Unanticipated harm to patients: deciding when to disclose outcomes. Jt Comm J Qual Saf 2003;29:551.

  • 5. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370376.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6. Milch CE, Salem DN, Pauker SG, et al. Voluntary electronic reporting of medical errors and adverse events: an analysis of 92,547 reports from 26 acute care hospitals. J Gen Intern Med 2006;21:165170.

    • Search Google Scholar
    • Export Citation
  • 7. Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med 1992;7:424431.

  • 8. Goldberg RM, Kuhn G, Andrew LB, et al. Coping with medical mistakes and errors in judgment. Ann Emerg Med 2002;39:287292.

  • 9. Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf 2007;33:467.

    • Search Google Scholar
    • Export Citation
  • 10. Pratt SD, Jachna BR. Care of the clinician after an adverse event. Int J Obstet Anesth 2015;24:5463.

  • 11. Scott SD, Hirschinger LE, Cox KR, et al. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care 2009;18:325330.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12. Smith ML, Forster HP. Morally managing medical mistakes. Camb Q Healthc Ethics 2000;9:3853.

  • 13. Gallagher TH, Waterman AD, Ebers AG, et al. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA 2003;289:10011007.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14. Schwappach DL, Boluarte TA. The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability. Swiss Med Wkly 2009;139:915.

    • Search Google Scholar
    • Export Citation
  • 15. Harrison R, Lawton R, Perlo J, et al. Emotion and coping in the aftermath of medical error: a cross-country exploration. J Patient Saf 2015;11:2835.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16. Landrigan CP, Bates DW, Czeisler CA, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med 2004;351:18381848.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17. Gaba DM, Howard SK. Patient safety: Fatigue among clinicians and the safety of patients. N Engl J Med 2002;347:12491255.

  • 18. Blendon RJ, Steffenson AM, DesRoches C, et al. Patient safety: views of practicing physicians and the public on medical errors. N Engl J Med 2002;347:19331940.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19. Harrison R, Lawton R, Stewart K. Doctors’ experiences of adverse events in secondary care: the professional and personal impact. Clin Med (Lond) 2014;14:585590.

    • Search Google Scholar
    • Export Citation
  • 20. World Health Organization. World alliance for patient safety: WHO draft guidelines for adverse event reporting and learning systems: from information to action. Geneva: World Health Organization, 2005;8.

    • Search Google Scholar
    • Export Citation
  • 21. McLennan SR, Engel-Glatter S, Meyer AH, et al. The impact of medical errors on Swiss anaesthesiologists: a cross-sectional survey. Acta Anaesthesiol Scand 2015;59:990998.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22. Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf 2010;36:233240.

    • Search Google Scholar
    • Export Citation
  • 23. Gardner DH, Hini D. Work-related stress in the veterinary profession in New Zealand. N Z Vet J 2006;54:119124.

  • 24. Hatch PH, Winefield HR, Christie BA, et al. Workplace stress, mental health, and burnout of veterinarians in Australia. Aust Vet J 2011;89:460468.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25. Lovell BL, Lee RT. Burnout and health promotion in veterinary medicine. Can Vet J 2013;54:790791.

  • 26. Mastenbroek NJJM, Jaarsma ADC, Demerouti E, et al. Burnout and engagement, and its predictors in young veterinary professionals: the influence of gender. Vet Rec 2014;174:144.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27. Nett RJ, Witte TK, Holzbauer SM, et al. Risk factors for suicide, attitudes toward mental illness, and practice-related stressors among US veterinarians. J Am Vet Med Assoc 2015;247:945955.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28. Sirriyeh R, Lawton R, Gardner P, et al. Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals’ psychological well-being. Qual Saf Health Care 2010;19:e43e48.

    • Search Google Scholar
    • Export Citation
  • 29. Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med 2005;20:559564.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30. Rosen IM, Gimotty PA, Shea JA, et al. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med 2006;81:8285.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31. Bellini LM, Shea JA. Mood change and empathy decline persist during three years of internal medicine training. Acad Med 2005;80:164167.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32. Haas JS, Cook EF, Puopolo AL, et al. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med 2000;15:122128.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33. Thomas NK. Resident burnout. JAMA 2004;292:28802889.

  • 34. Shanafelt TD, Bradley KA, Wipf JE, et al. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358367.

    • Crossref
    • Search Google Scholar
    • Export Citation

Supplementary Materials

Contributor Notes

Address correspondence to Dr. Schoenfeld-Tacher (regina_schoenfeld@ncsu.edu).
  • 1. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ 2016;353:i2139.

  • 2. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg 2010;251:9951000.

  • 3. Wu AW, Folkman S, McPhee SJ, et al. Do house officers learn from their mistakes? JAMA 1991;265:20892094.

  • 4. Barron WM, Kuczewski MG. Unanticipated harm to patients: deciding when to disclose outcomes. Jt Comm J Qual Saf 2003;29:551.

  • 5. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370376.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6. Milch CE, Salem DN, Pauker SG, et al. Voluntary electronic reporting of medical errors and adverse events: an analysis of 92,547 reports from 26 acute care hospitals. J Gen Intern Med 2006;21:165170.

    • Search Google Scholar
    • Export Citation
  • 7. Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med 1992;7:424431.

  • 8. Goldberg RM, Kuhn G, Andrew LB, et al. Coping with medical mistakes and errors in judgment. Ann Emerg Med 2002;39:287292.

  • 9. Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf 2007;33:467.

    • Search Google Scholar
    • Export Citation
  • 10. Pratt SD, Jachna BR. Care of the clinician after an adverse event. Int J Obstet Anesth 2015;24:5463.

  • 11. Scott SD, Hirschinger LE, Cox KR, et al. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care 2009;18:325330.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12. Smith ML, Forster HP. Morally managing medical mistakes. Camb Q Healthc Ethics 2000;9:3853.

  • 13. Gallagher TH, Waterman AD, Ebers AG, et al. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA 2003;289:10011007.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14. Schwappach DL, Boluarte TA. The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability. Swiss Med Wkly 2009;139:915.

    • Search Google Scholar
    • Export Citation
  • 15. Harrison R, Lawton R, Perlo J, et al. Emotion and coping in the aftermath of medical error: a cross-country exploration. J Patient Saf 2015;11:2835.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16. Landrigan CP, Bates DW, Czeisler CA, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med 2004;351:18381848.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17. Gaba DM, Howard SK. Patient safety: Fatigue among clinicians and the safety of patients. N Engl J Med 2002;347:12491255.

  • 18. Blendon RJ, Steffenson AM, DesRoches C, et al. Patient safety: views of practicing physicians and the public on medical errors. N Engl J Med 2002;347:19331940.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19. Harrison R, Lawton R, Stewart K. Doctors’ experiences of adverse events in secondary care: the professional and personal impact. Clin Med (Lond) 2014;14:585590.

    • Search Google Scholar
    • Export Citation
  • 20. World Health Organization. World alliance for patient safety: WHO draft guidelines for adverse event reporting and learning systems: from information to action. Geneva: World Health Organization, 2005;8.

    • Search Google Scholar
    • Export Citation
  • 21. McLennan SR, Engel-Glatter S, Meyer AH, et al. The impact of medical errors on Swiss anaesthesiologists: a cross-sectional survey. Acta Anaesthesiol Scand 2015;59:990998.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22. Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf 2010;36:233240.

    • Search Google Scholar
    • Export Citation
  • 23. Gardner DH, Hini D. Work-related stress in the veterinary profession in New Zealand. N Z Vet J 2006;54:119124.

  • 24. Hatch PH, Winefield HR, Christie BA, et al. Workplace stress, mental health, and burnout of veterinarians in Australia. Aust Vet J 2011;89:460468.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25. Lovell BL, Lee RT. Burnout and health promotion in veterinary medicine. Can Vet J 2013;54:790791.

  • 26. Mastenbroek NJJM, Jaarsma ADC, Demerouti E, et al. Burnout and engagement, and its predictors in young veterinary professionals: the influence of gender. Vet Rec 2014;174:144.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27. Nett RJ, Witte TK, Holzbauer SM, et al. Risk factors for suicide, attitudes toward mental illness, and practice-related stressors among US veterinarians. J Am Vet Med Assoc 2015;247:945955.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28. Sirriyeh R, Lawton R, Gardner P, et al. Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals’ psychological well-being. Qual Saf Health Care 2010;19:e43e48.

    • Search Google Scholar
    • Export Citation
  • 29. Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med 2005;20:559564.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30. Rosen IM, Gimotty PA, Shea JA, et al. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med 2006;81:8285.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31. Bellini LM, Shea JA. Mood change and empathy decline persist during three years of internal medicine training. Acad Med 2005;80:164167.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32. Haas JS, Cook EF, Puopolo AL, et al. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med 2000;15:122128.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33. Thomas NK. Resident burnout. JAMA 2004;292:28802889.

  • 34. Shanafelt TD, Bradley KA, Wipf JE, et al. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358367.

    • Crossref
    • Search Google Scholar
    • Export Citation

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