Consequences of defensive medicine, second victims, and clinical-judicial syndrome on surgeons’ medical practice and on health service

The European Researchers' Network Working on Second Victim (ERNST) Policy Statement on the Second Victim Phenomenon for Increasing Patient Safety

Background

The second victim phenomenon refers to the emotional trauma healthcare professionals experience following adverse events (AEs) in patient care, which can compromise their ability to provide safe care. This issue has significant implications for patient safety, with AEs leading to substantial human and economic costs.

Analysis

Current evidence indicates that AEs often result from systemic failures, profoundly affecting healthcare workers. While patient safety initiatives are in place, the psychological impact on healthcare professionals remains inadequately addressed. The European Researchers' Network Working on Second Victims (ERNST) emphasizes the need to support these professionals through peer support programs, systemic changes, and a shift toward a just culture in healthcare settings.

Policy Options

Key options include implementing peer support programs, revising the legal framework to decriminalize honest errors, and promoting just culture principles. These initiatives aim to mitigate the second victim phenomenon, enhance patient safety, and reduce healthcare costs.

Conclusion

Addressing the second victim phenomenon is essential for ensuring patient safety. By implementing supportive policies and fostering a just culture, healthcare systems can better manage the repercussions of AEs and support the wellbeing of healthcare professionals.

Management and patient outcomes following admission with acute cholecystitis in Ireland: A national registry-based study

INTRODUCTION

Acute cholecystitis is a common general surgical emergency, accounting for 3-10 % of all patients attending with acute abdominal pain. International guidelines suggest that emergency cholecystectomy is the treatment of choice for uncomplicated acute cholecystitis where feasible. There is a paucity of published data on the uptake of emergency cholecystectomy in Ireland.

AIM

The aim of this study was to evaluate the management of acute cholecystitis in Ireland and to establish the rate of emergency cholecystectomy performed.

METHODS

All patients with acute cholecystitis presenting to public hospitals in Ireland between January 2017 and July 2023 were identified using the National Quality Assurance and Improvement System (NQAIS). Data were collected on patient demographics, co-morbidities, length of stay, operative intervention, endoscopic intervention, critical care admissions, in-patient mortality, and readmissions. Propensity score matched analysis and logistic regression were performed to account for selection bias in comparing patients managed with cholecystectomy and those managed conservatively.

RESULTS

20,886 admission episodes were identified involving 17,958 patients. 3585 (20 %) patients underwent emergency cholecystectomy in total. 3436 (96 %) of these were performed laparoscopically, with 140 (4 %) requiring conversion to an open procedure, and common bile duct injuries occurring in 4 (0.1 %) of patients. In comparison to patients treated conservatively, patients who underwent cholecystectomy were younger (median 50 v 60 years, p < 0.001) and more likely to be female (64 % v 55 % p < 0.001). Following propensity score matched analysis, those who had an emergency cholecystectomy had reduced length of stay (LOS) (median 5 days (IQR 3-8) v 6 days (interquartile range (IQR) 3-10), p < 0.001) and fewer readmissions to hospital (282 (8 %) v 492 (14 %), p < 0.001). On logistic regression, age >65 (OR 1.526), CCI >3 (OR 2.281) and non-operative management (OR 1.136) were significant risk factors for adverse outcome.

CONCLUSION

Uptake of emergency cholecystectomy in Ireland remains low, and is carried out on a younger, fitter cohort of patients. In those patients, however, it is associated with improved outcomes for cholecystitis compared to conservative management, including shorter LOS and reduced readmission rates for matched cohorts.

The impact of surgical complications on obstetricians' and gynecologists' well-being and coping mechanisms as second victims

BACKGROUND

Obstetrics and gynecology surgery is becoming increasingly complex because of an aging population with increasing rates of medical comorbidities and obesity. Complications are therefore common, and not only impact the patient but can also cause distress to the obstetrics and gynecology surgeon as a "second victim."

OBJECTIVE

This study aimed to describe and quantify the range of effects of complications on obstetrics and gynecology surgeons, and assess sociodemographic, clinician, and practice factors associated with such impact.

STUDY DESIGN

A cross-sectional survey was developed on the basis of interviews with obstetrics and gynecology surgeons and a review of the literature. The survey assessed obstetrics and gynecology surgeons' demographic, clinical, and practice characteristics; estimated the number of complications per year and the impact of complications on distress, physical and mental health, sleep, and relationships; and explored strategies that obstetrics and gynecology surgeons used to cope with complications. Univariate logistic regression analyses were used to determine the association between obstetrics and gynecology surgeons' characteristics and complication consequences.

RESULTS

Overall, of 727 survey respondents, 431 (61%) were female, 384 (55%) were aged ≥50 years, almost half had worked as obstetrics and gynecology surgeons for ≥15 years (329 [45%]), and 527 (73%) reported completing <10 surgical procedures per week. Most (568 [78%]) reported <3 surgical complications per year, and most (472 [66%]) thought this was similar or less frequent compared with their colleagues. Complications caused most stress when they resulted in poor patient outcomes (653 [90%]), had severe patient consequences (630 [87%]), or were a result of surgeon error (627 [86%]). Complications impacted most obstetrics and gynecology surgeons' well-being and sleep. A greater proportion of those aged <50 years reported that their mental well-being (32 [10%]; P=.002) and sleep (130 [42%]; P=.03) were affected when a complication occurred. Female participants were also more likely to report that their physical health (14 [3%]; P≤.001), mental health (39 [9%]; P=.01), and sleep (183 [43%]; P≤.001) were affected. Current trainees (11 [10%]) and surgeons with <15 years of experience (25 [9%]) were more likely to experience mental well-being consequences compared with surgeons with ≥15 years of experience (12 [4%]; P=.01). Female participants reported less willingness to interact with colleagues when complications occurred (323 [75%]; P=.006), and surgeons with <15 years of training were less likely to report comfort in talking (221 [74%]; P=.03) and interacting with others (212 [74%]; P=.02).

CONCLUSION

The vast majority of obstetrics and gynecology surgeons experience a major impact on their health and well-being when one of their patients develops a complication. The degree and type of impact reported are similar to those observed in other surgical specialties. Future studies are needed to test interventions that alleviate the substantial impact and to follow obstetrics and gynecology surgeons longitudinally to understand the duration of the impact of complications.

The influence of fears of perceived legal consequences on general practitioners' practice in relation to defensive medicine - a cross-sectional survey in Germany

BACKGROUND

Medical decisions are influenced by a variety of factors also by legal requirements and feelings of uncertainty, which results in the term defensive medicine. The aim of the study was to evaluate the influence of fears of perceived legal consequences on the practice of defensive medicine from the perspective of German general practitioners (GPs).

METHODS

A cross-sectional study was performed from April to May 2022. GPs were invited via an e-mail newsletter of the Institute for Continuing Education in Family Medicine in the German Association of General Practitioners and via an online platform of the German College of General Practitioners and Family Physicians. The evaluation of legal fears, the general assessment of defensive medicine and reasons for and the frequency of defensive medical measures were surveyed in this study. Beside descriptive analyses, a stepwise linear regression analysis was used to explore potential associations between for the primary outcome variable 'fears of legal consequences' on the practice of defensive medicine.

RESULTS

413 general practitioners with an average age of 50 years (51% female) responded. The majority rated their fears of legal consequences as low to average whereas for almost a third (27%, n = 113) the fears were strong to very strong. Regarding legal fears, the physician-patient-relationship played a fairly to very large role for 48% (n = 198) of the respondents. One third estimated the probability of being sued civilly in the next 10 years as rather high to very high. 47% (n = 193) of the participants assumed that the risk of being sued could mostly to very much be reduced by defensive medicine. Legal self-protection was for 38% of the responders (n = 157) quite frequently to very frequently a reason for acting defensively. Consequently, half of the respondents stated that they performed unnecessary laboratory tests at least once per week and 40% indicated that they referred patients for radiological diagnostics without medical indication once per month.

CONCLUSIONS

As legal fears have an influence on medical practice and legal self-protection being a frequent reason for defensive behaviour, understanding and knowledge of the law should be improved by legal education at university and further training of post-graduate trainees and practicing physicians should be implemented. Additionally, a more in-depth enlightenment of society about the phenomenon of Protective and Defensive Medicine and its consequences could be a possibility to decrease the perceived fears of legal consequences on the physicians' side.

The practice of defensive medicine among Jordanian physicians: A cross sectional study

BACKGROUND

Defensive medicine (DM) is a deviation from medical practice that is induced primarily by a threat of liability. While the DM behavior is well studied in the developed countries, little is known in developing countries and never been evaluated in Jordan.

OBJECTIVE

To evaluate the prevalence of DM practice in Jordan among physicians and to investigate reasons behind its practice and potential strategies to alleviate this practice.

METHODS

In this Cross-sectional study, self-administered questionnaire was distributed to a sample of physicians in both public and private sectors in Jordan. The collection period was from Jan 2021 to June 2021. The prevalence of DM practice was estimated among the study sample. Frequency scores of different DM behaviors, reasons of DM behaviors, and effectiveness of strategies in changing DM behaviors were summarized as average frequency scores with standard deviations. Multivariable linear regression models were conducted to evaluate potential predictors of total assurance and avoidance behavior scores.

RESULTS

A total of 175 Jordanian physicians completed the survey. The prevalence of adopting (or witnessing) DM behaviors among the study sample was 68% (n = 119). Diagnostic laboratory exams followed by prescribed medications were the most practiced behaviors in excessive rate during a typical working week. Unfavorable legislation for the physician was reported as the headmost reason for practicing DM, followed by pressure from the public and mass media opinion. Continuous update of knowledge, abilities, and performance and following specific protocols and/or appropriate clinical evidence and appropriate multidisciplinary and multi-professional communication were the most effective strategies that can mitigate DM behaviors.

CONCLUSIONS

Defensive medicine practice is common among Jordanian physicians with concerns about increasing pattern in the future.

Practice of defensive medicine among surgeons in Ethiopia: cross-sectional study

BACKGROUND

Defensive medicine is physicians' deviation from standard medical care which is primarily intended either to reduce or avoid medico legal litigation. Although the Federal Ethics Committee review in Ethiopia has shown that applications for medical/surgical error investigation claims are increasing at an alarming rate, there is no study to date done to estimate the degree of defensive practice done by the physicians with an intention of avoiding this increasing legal claim. This study assessed the practice of defensive medicine among highly litigious disciplines (surgery) and described factors associated with its practice.

METHODS

Cross sectional quantitative study using online survey questionnaires was conducted to assess the degree of defensive practice and six factors (age, years of experience, specialty, monthly income, place of practice and previous medico legal history) associated with its practice were assessed among surgeons working in Ethiopia.

RESULTS

A total of 430 surgeons directly received an online survey questionnaire and 236 of them successfully completed the questionnaire making the response rate 51.2%. Nearly half of the study participants (51.7%) were aware of the concept of defensive medicine and 174 (74%) reported performing one form of defensive practice. Twenty-nine (12.3%) of the participants have legal dispute history, though only 1.3% of them ended up in penalty. Avoiding high risk procedures was the commonest defensive act performed by 60% of the participants, followed by ordering tests unnecessarily (52.1%). Multinomial logistic regression model showed that there was no association between age of the participant, place of practice, year of experience and defensive practice. This model also showed that cardiothoracic and vascular surgeons perform less defensively than surgeons with other specialty with P value of 0.02.

CONCLUSION

The practice of defensive medicine is widespread among surveyed Ethiopian surgeons and further studies are required to objectively estimate the effect of defensive practice on the health care system of the country. Policy makers need to develop strategy towards decreasing this high rate of defensive practice.

Predictors of Defensive Practices among Italian Psychiatrists: Additional Findings from a National Survey

Background: Defensive medicine is characterized by medical decisions made primarily as a precaution against potential malpractice claims. For psychiatrists, professional responsibility encompasses not only the appropriateness of diagnosis and treatment but also the effects of their interventions on patients and their behaviors. Objective: To investigate the socio-demographic, educational, and occupational characteristics and work-related attitudes that may serve as predictors of defensive medicine among Italian psychiatrists. This research extends the results of a previous analysis based on a national survey. Methods: A secondary analysis of the database of a national survey on attitudes and behaviors of Italian psychiatrists regarding defensive medicine and professional liability was performed for this study. Results: Among 254 surveyed psychiatrists, 153 admitted to practicing defensive medicine, while 101 had this attitude with less than half of their patients. The first group was predominantly comprised of women (p = 0.014), who were younger in age (43.34 y 9.89 vs. 48.81 y 11.66, p < 0.001) and had fewer years of professional experience (12.09 y ± 9.8 vs. 17.46 y ± 11.2, p < 0.001). There were no significant differences in prior involvement in complaints (p = 0.876) or the usual place of work (p = 0.818). The most prominent predictors for practicing defensive medicine were (1) considering guidelines and good clinical practices not only for their clinical efficacy but also or exclusively for reducing the risk of legal complaints for professional liability (OR = 3.62; 95%CI, 1.75-7.49), and (2) hospitalizing patients with violent intentions even if not warranted according to their mental state (OR = 2.28; 95%CI, 1.50-3.46, p < 0.001). Prioritizing protection from professional liability over patients' actual needs in prescribing or adjusting drug dosages and in involuntary hospitalization, as well as prescribing lower dosages than recommended for pregnant patients, were identified as additional predictors. Finally, years of professional experience exhibited a protective function against defensive practices. Conclusions: Psychiatrists advocate the need to implement a 'risk management culture' and the provision of more balanced duties in order to ensure ethical and evidence-based care to their patients. A particular source of concern stems from their professional responsibility towards not only the health of patients but also their behavior. However, these aspects conflict with a limited potential for assessment and intervention based on effective clinical tools. A reform of professional liability that considers the specificities of patients cared for by mental health services could contribute to reducing the risk of defensive medicine.

Predictors of Defensive Practices among Italian Psychiatrists: Additional Findings from a National Survey

Background: Defensive medicine is characterized by medical decisions made primarily as a precaution against potential malpractice claims. For psychiatrists, professional responsibility encompasses not only the appropriateness of diagnosis and treatment but also the effects of their interventions on patients and their behaviors. Objective: To investigate the socio-demographic, educational, and occupational characteristics and work-related attitudes that may serve as predictors of defensive medicine among Italian psychiatrists. This research extends the results of a previous analysis based on a national survey. Methods: A secondary analysis of the database of a national survey on attitudes and behaviors of Italian psychiatrists regarding defensive medicine and professional liability was performed for this study. Results: Among 254 surveyed psychiatrists, 153 admitted to practicing defensive medicine, while 101 had this attitude with less than half of their patients. The first group was predominantly comprised of women (p = 0.014), who were younger in age (43.34 y 9.89 vs. 48.81 y 11.66, p < 0.001) and had fewer years of professional experience (12.09 y ± 9.8 vs. 17.46 y ± 11.2, p < 0.001). There were no significant differences in prior involvement in complaints (p = 0.876) or the usual place of work (p = 0.818). The most prominent predictors for practicing defensive medicine were (1) considering guidelines and good clinical practices not only for their clinical efficacy but also or exclusively for reducing the risk of legal complaints for professional liability (OR = 3.62; 95%CI, 1.75–7.49), and (2) hospitalizing patients with violent intentions even if not warranted according to their mental state (OR = 2.28; 95%CI, 1.50–3.46, p < 0.001). Prioritizing protection from professional liability over patients’ actual needs in prescribing or adjusting drug dosages and in involuntary hospitalization, as well as prescribing lower dosages than recommended for pregnant patients, were identified as additional predictors. Finally, years of professional experience exhibited a protective function against defensive practices. Conclusions: Psychiatrists advocate the need to implement a ‘risk management culture’ and the provision of more balanced duties in order to ensure ethical and evidence-based care to their patients. A particular source of concern stems from their professional responsibility towards not only the health of patients but also their behavior. However, these aspects conflict with a limited potential for assessment and intervention based on effective clinical tools. A reform of professional liability that considers the specificities of patients cared for by mental health services could contribute to reducing the risk of defensive medicine.

Defensive medicine through the lens of the managerial perspective: a literature review

PURPOSE

Several studies have been carried out on defensive medicine, but research from the managerial viewpoint is still scarce. Therefore, the aim of the present study is to conduct a literature review to better understand defensive medicine from a managerial perspective.

DESIGN/METHODOLOGY/APPROACH

A literature review was conducted of studies focusing on the organisational (meso) level of healthcare providers and managerial practices. A final sample of 28 studies was processed.

FINDINGS

Defensive medicine has mainly been studied in the USA, and scholars have principally used quantitative surveys. High-risk specialities have been a critical field of investigation, and a large portion of the papers are published in journals that cover medicine, health policy, education and law fields. The analysis showed that operations and the organisation of staffing were the most discussed managerial practices. No study considered planning and budgeting aspects.

ORIGINALITY/VALUE

The review confirmed that the managerial aspect of defensive medicine has not been fully addressed. Stimulated by this gap, this study analyses the managerial background of the defensive medicine phenomenon and shows which managerial practices have been most analysed. This paper also contributes to developing the literature on defensive medicine from the managerial side. Areas for future research include qualitative studies to investigate the behaviour of managers of healthcare companies to give a different perspective on defensive medicine and organisations' decision-making.

RESEARCH LIMITATIONS/IMPLICATIONS

Some important publications might have been missed in this work because of the choice of only two databases. A further limit could be imposed by the use of the English language as an inclusion criterion.

Exploring defensive medicine: examples, underlying and contextual factors, and potential strategies - a qualitative study

BACKGROUND

Medical errors, unsatisfactory outcomes, or treatment complications often prompt patient complaints about healthcare providers. In response, physicians may adopt defensive practices to mitigate objections, avoid complaints, and navigate lengthy trial processes or other potential threats. However, such defensive medicine (DM) practices can carry risks, including potential harm to patients and the imposition of unnecessary costs on both patients and the healthcare system. Moreover, these practices may run counter to accepted ethical standards in medicine.

METHODS

This qualitative study involved conducting semi-structured interviews with 43 physicians, among whom 38 were faculty members at medical universities, 42 had administrative experience at various levels of the health system, and 23 had previously served as health system policymakers. On average, the participants had approximately 23.5 years of clinical experience. The selection of participants was based on purposive sampling. Data collection through interviews continued until data saturation was achieved.

RESULTS

Based on the findings, DM manifests in both positive and negative forms, illustrated by instances like ordering unnecessary lab tests, imaging, or consultations, reluctance to admit high-risk patients, and avoiding high-risk procedures. The study participants identified a range of underlying and contextual factors contributing to DM, encompassing organizational-managerial, social, personal, and factors inherent to the nature of defensive medical practices. The results also highlight proposed strategies to address and prevent DM, which can be grouped into organizational-managerial, social, and those focused on modifying the medical complaints management system.

CONCLUSION

DM is a multifaceted and significant phenomenon that necessitates a comprehensive understanding of its various aspects, including interconnected and complex structures and underlying and contextual factors. While the results of this study offer a solid foundation for informing policy decisions within the healthcare system and include some explanatory policy suggestions, we encourage policymakers to complement the findings of this study with other available evidence to address any potential limitations and to gain a more comprehensive understanding of the policymaking process related to DM.

Collateral Victims of Defensive Medical Practice

This paper analyzes the phenomenon of defensive medical practice, starting from the doctor–patient relationship, and the behavioral and professional factors that can influence the proper functioning of this relationship and the healthcare system. We analyze medical malpractice, given the increase in the number of accusations, as an essential factor in triggering the defensive behavior of doctors, together with other complementary factors that emphasize the need for protection and safety of doctors. The possible consequences for the doctor–patient relationship that defensive practice can generate are presented and identified by analyzing the determining role of the type of health system (fault and no-fault). At the same time, we investigate the context in which overspecialization of medical personnel can generate a form of defensive practice as a result of the limiting effect on the performance of a certain category of operations and procedures. The increase in the number of malpractice accusations impacts the medical community—“the stress syndrome induced by medical malpractice”—turning doctors into collateral victims who, under the pressure of diminishing their reputational safety, practice defensively to protect themselves from future accusations. This type of defensive behavior puts pressure on the entire healthcare system by continuously increasing costs and unresolved cases, which impact patients by limiting access to medical services in the public and private sectors.

Personalized decision-making for acute cholecystitis: Understanding surgeon judgment

Background

There is sparse high-level evidence to guide treatment decisions for severe, acute cholecystitis (inflammation of the gallbladder). Therefore, treatment decisions depend heavily on individual surgeon judgment, which is highly variable and potentially amenable to personalized, data-driven decision support. We test the hypothesis that surgeons' treatment recommendations misalign with perceived risks and benefits for laparoscopic cholecystectomy (surgical removal) vs. percutaneous cholecystostomy (image-guided drainage).

Methods

Surgery attendings, fellows, and residents applied individual judgement to standardized case scenarios in a live, web-based survey in estimating the quantitative risks and benefits of laparoscopic cholecystectomy vs. percutaneous cholecystostomy for both moderate and severe acute cholecystitis, as well as the likelihood that they would recommend cholecystectomy.

Results

Surgeons predicted similar 30-day morbidity rates for laparoscopic cholecystectomy and percutaneous cholecystostomy. However, a greater proportion of surgeons predicted low (<50%) likelihood of full recovery following percutaneous cholecystostomy compared with cholecystectomy for both moderate (30% vs. 2%, p < 0.001) and severe (62% vs. 38%, p < 0.001) cholecystitis. Ninety-eight percent of all surgeons were likely or very likely to recommend cholecystectomy for moderate cholecystitis; only 32% recommended cholecystectomy for severe cholecystitis (p < 0.001). There were no significant differences in predicted postoperative morbidity when respondents were stratified by academic rank or self-reported ability to predict complications or make treatment recommendations.

Conclusions

Surgeon recommendations for severe cholecystitis were discordant with perceived risks and benefits of treatment options. Surgeons predicted greater functional recovery after cholecystectomy but less than one-third recommended cholecystectomy. These findings suggest opportunities to augment surgical decision-making with personalized, data-driven decision support.

The Effect of Second-Victim-Related Distress and Support on Work-Related Outcomes in Tertiary Care Hospitals in Kelantan, Malaysia

After a patient safety incident, the involved healthcare providers may experience sustained second-victim distress and reduced professional efficacy, with subsequent negative work-related outcomes and the cultivation of resilience. This study aims to investigate the factors affecting negative work-related outcomes and resilience with a hypothetical triad of support as the mediators: colleague, supervisor, and institutional support. This cross-sectional study recruited 733 healthcare providers from three tertiary care hospitals in Kelantan, Malaysia. Three steps of hierarchical linear regression were developed for both outcomes (negative work-related outcomes and resilience). Four multiple mediator models of the support triad were analyzed. Second-victim distress, professional efficacy, and the support triad contributed significantly in all the regression models. Colleague support partially mediated the relationship defining the effects of professional efficacy on negative work-related outcomes and resilience, whereas colleague and supervisor support partially mediated the effects of second-victim distress on negative work-related outcomes. Similar results were found regarding resilience, with all support triads producing similar results. As mediators, the support triads ameliorated the effect of second-victim distress on negative work-related outcomes and resilience, suggesting an important role of having good support, especially after encountering patient safety incidents.

The Impact of Patient Deaths on General Surgeons’ Psychosocial Well-Being and Surgical Practices

Background

Patient deaths are an unavoidable occurrence in surgical practice. Although these events have negative effects on patients and their families, they can also have a profound adverse impact on surgeons who are unprepared for these deep emotional experiences. This study aims to investigate the impact of patient deaths on general surgeons’ psychosocial well-being and surgical practices.

Methods

A national cross-sectional survey of a 30-item questionnaire was conducted. The survey evaluated the surgeons’ demographics, professional and practice characteristics, and the impact of patient deaths on their emotional well-being, professional career, and social life.

Results

Four hundred eighty participants completed the survey. One-third of the participants reported that patient deaths affected their emotional well-being, 23.3% reported that patient deaths affected their social life, and 34.2% reported that patient deaths affected their professional career. Surgeons who reported suffering from the emotional impact of death exhibited no differences in terms of place of practice, academic title, surgical experience, work hours, or annual surgical volume. Middle-aged surgeons (p = 0.004), females (p = 0.041), and surgeons who reported feeling burned out (p < 0.001) were more likely to be affected by patient loss. Feelings of sadness, worry, and stress were most reported. A total of 18.1% of the participants indicated that they considered taking a break after patient death, and 11.9% thought they would abandon their surgical career.

Conclusions

The findings of this study suggest that patient death affects surgeons’ psychosocial well-being and surgical practices. Greater awareness and effort are required at the personal, institutional, and organizational level to provide effective support, helping surgeons to cope with the emotional burden of patient deaths.

Second-victim Experience and Support Desire Among Nurses Working at Regional Levels in China

AIM

To describe and analyse the degree of second victim syndrome and the desire for supports among nurses working in regional hospitals in China.

BACKGROUND

The evidence on the prevalence of second victim among healthcare workers remains inconsistent and have rarely focused on the regional level.

METHODS

A quantitative, descriptive, survey-based, online, cross-sectional study was conducted among 1,194 nurses in three regional hospitals.

RESULTS

A total of 918 (76.88%) nurses, who reported have had experienced patient safety incidents, were selected for the final analysis. The mean score for the Chinese version of the Second Victim Experience and Support Tool (C-SVEST) was (65.58±10.05). Psychological distress (15.91±2.99) and practice distress (15.26±4.32) had the highest score. The mean score for the desired form of support was (4.29±0.614). The option 'the opportunity to get guidance and suggestions for future work' was rated the most desired.

CONCLUSION

Nurses working at the regional level reported a similar degree of second victim experience and support desire, while the prevalence was much higher.

IMPLICATIONS FOR NURSING MANAGEMENT

The second victim phenomenon has become increasingly complex and challenging, and deserve more attention. Not only Safety-I, abut also Safety-II approaches are suggested to integrated to patient safety.

Translation and Validation of the Malay Revised Second Victim Experience and Support Tool (M-SVEST-R) among Healthcare Workers in Kelantan, Malaysia

“Second victims” are defined as healthcare professionals who are traumatized physically, psychologically, or emotionally as a result of encountering any patient safety incidents. The Revised Second Victim Experience and Support Tool (SVEST-R) is a crucial instrument acknowledged worldwide for the assessment of the second victim phenomenon in healthcare facilities. Hence, the aim of this study was to evaluate the psychometric properties of the Malay version of the SVEST-R. This was a cross-sectional study that recruited 350 healthcare professionals from a teaching hospital in Kelantan, Malaysia. After obtaining permission from the original author, the instrument underwent 10 steps of established translation process guidelines. Pretesting of 30 respondents was performed before embarking on the confirmatory factor analysis (CFA) to evaluate internal consistency and construct validity. The analysis was conducted using the R software environment. The final model agreed for 7 factors and 32 items per the CFA’s guidelines for good model fit. The internal consistency was determined using Raykov’s rho and showed good results, ranging from 0.77 to 0.93, with a total rho of 0.83. The M-SVEST-R demonstrated excellent psychometric properties and adequate validity and reliability. This instrument can be used by Malaysian healthcare organizations to assess second victim experiences among healthcare professionals and later accommodate their needs with the desired support programs.

Defensive medicine in Danish general practice. Types of defensive actions and reasons for practicing defensively

OBJECTIVE

To examine the occurrence of and types of defensive medicine (DM), and the reasons for practicing DM in general practice.

DESIGN

Prospective survey registration of consecutive consultations regarding defensive medicine defined as: Actions that are not professionally well founded but are carried out due to demands and pressure. The GPs registered the degree of defensiveness, the type(s) of defensive action(s) and the reason(s) for acting defensively.

SETTING

Danish general practice.

SUBJECTS

A total of 26 GPs registered a total of 1,758 consultations.

MAIN OUTCOME MEASURES

Defensive medical actions.

RESULTS

Defensive actions were performed in 12% (210/1749) of all consultations. A fifth (46/210) of the defensive actions were characterised by the GPs as 'moderately' or 'highly' defensive. Frequent types of defensive actions were: blood tests, point-of-care-tests (POCTs) and referrals. Common reasons for defensive actions were: Influence from patients, 37% (78/210), concerns of overlooking severe disease, 32% (67/210) and influence from patient relatives, 12% (25/210).

CONCLUSION

Danish GPs registered self-perceived defensive actions in a prospective survey. DM was carried out in one out of eight consultations, most often due to patient influence. The most frequent defensive actions were blood tests, POCTs and referrals.

Student Nurses' Experiences of Critical Events in the Clinical Setting: A Grounded Theory

BACKGROUND

Nursing students often experience critical events in the clinical setting and clinical instructors may not be prepared to adequately support them. These students often feel alone and abandoned, increasing their risk of psychological distress.

PURPOSE

A grounded theory study was conducted to explore pre-licensure nursing students' experiences of critical events in the clinical setting. Specific attention was paid to understanding how they are prepared for and supported before, during, and after critical events, and their experiences of psychological distress and psychological recovery.

METHOD

Strauss and Corbin's Grounded Theory methodology was used for this study.

RESULTS

Fourteen undergraduate student nurses from universities in the western United States were interviewed. Ten concepts were identified, and a theory of Student Nurses' Experiences of Critical Events in the Clinical Setting emerged.

CONCLUSION

Findings indicate that student nurses need active instructor and/or staff support during critical events, and pre-briefing whenever possible. Debriefing positively affected students' post-event stress response and lack of debrief was associated with post-event psychological distress. Support for students exposed to critical events during clinical experiences should continue in the days, weeks, and months following the event; clinical instructors need to be prepared to provide this support. All faculty members should monitor students for signs of psychological distress and better support students' mental health and emotional wellbeing.

The hidden experience of nursing professionals sued for error

OBJECTIVE

To understand the experience of judicialization due to error from the viewpoint of nursing professionals.

METHOD

Qualitative study with two nursing professionals sued for error in a state in southern Brazil. The data were collected between January and June 2018 through an online survey and analyzed with the Oral History technique.

RESULTS

The reports discussed the experience of error and its influence on professional practice. The perception of being unable to intervene in errors and the lack of support from institutions and professional associations were mentioned as causes of emotional suffering, a feeling of injustice, and revolt. Nonetheless, both participants mentioned receiving support from the local health sector union and hoping to carry on with their profession.

CONCLUSION

Emotional suffering caused by judicialization is amplified by a feeling of helplessness regarding error prevention and lack of institutional support.

Defensive practice is indefensible: how defensive medicine runs counter to the ethical and professional obligations of clinicians

Defensive medicine has become pervasive. Defensive medicine is often thought of as a systems issue, the inevitable result of an adversarial malpractice environment, with consequent focus on system-responses and tort reform. But defensive medicine also has ethical and professionalism implications that should be considered beyond the need for tort reform. This article examines defensive medicine from an ethics and professionalism perspective, showing how defensive medicine is deeply problematic. First, a definition of defensive medicine is offered that describes the essence of defensive practice: clinical actions with the goal of protecting the clinician against litigation or some adverse outcome. Ethical arguments against defensive medicine are considered: (1) defensive medicine is deceptive and undermines patient autonomy; (2) defensive medicine subjugates patient interests to physician interests and violate fiduciary obligations; (3) defensive medicine exposes patients to harm without benefit; (4) defensive medicine undermines trust in the profession; and (5) defensive medicine violates obligations of justice. Possible arguments in favor of defensive medicine are considered and refuted. Defensive practice is therefore unethical and unprofessional, and should be viewed as a challenge for medical ethics and professionalism.

Dealing With Adverse Events: A Meta-analysis on Second Victims' Coping Strategies

OBJECTIVES

Despite the critical need to understand the diverse responses by second victims to adverse events, there has not been a meta-analysis examining coping by second victims. We aimed to analyze the coping strategies applied by second victims in the aftermath of adverse events.

METHODS

We performed a systematic search of nine electronic databases up to October 2018 and screened additional sources, such as gray databases. Two independent reviewers conducted the search, selection process, quality appraisal, data extraction, and synthesis. In case of dissent, a third reviewer was involved to reach consensus. Quantitative studies of the frequency with which coping strategies were applied by second victims were eligible for inclusion. We calculated the overall frequency of coping strategies and I statistic using random effects modeling.

RESULTS

Of 10,705 records retrieved, 111 full-text articles were assessed for eligibility and 14 studies eventually included. The five most frequent coping strategies were Changing work attitude (89%, 95% confidence interval [CI] = 80-94), Following policies and guidelines more accurately and closely (89%, 95% CI = 54-98), Paying more attention to detail (89%, 95% CI = 78-94) (task oriented), Problem-solving/concrete action plan (77%, 95% CI = 59-89) (task oriented), and Criticizing or lecturing oneself (74%, 95% CI = 47-90) (emotion oriented).

CONCLUSIONS

Second victims frequently used task- and emotion-oriented coping strategies and, to a lesser degree, avoidance-oriented strategies. To better support second victims and ensure patient safety, coping strategies should be evaluated considering the positive and negative effects on the clinician's personal and professional well-being, relationships with patients, and the quality and safety of healthcare.

Low-Value Clinical Practices: Knowledge and Beliefs of Spanish Surgeons and Anesthetists

OBJECTIVES: To know the frequency and causes of low value surgical practices, according to the opinion of surgeons and anesthetists, and to determine their degree of knowledge about the Spanish "Choosing wisely" initiative. METHODS: Cross-sectional observational study, based on a self-administered online questionnaire through an opportunistic sample of 370 surgeons and anesthetists from three Spanish regions, contacted through Scientific Societies. The survey took part between July and December 2017. RESULTS: A patient profile requesting unnecessary practices was identified (female, 51-65 years old and unaffiliated disease). The frequency of requests was weekly or daily for 50.0% of the professionals, of whom 15.1% acknowledged succumbing to these pressures. To dissuade the patient, clinical reasons (47%) were considered the most effective. To increase control and safety in the case was the main reason to indicate them. The greatest responsibility for overuse was attributed to physicians, defensive medicine and mass media. Assessing professionals' knowledge on unnecessary practices, an average of 5 correct answers out of 7 was obtained. Some 64.1% of the respondents were unaware of the Spanish "Choosing wisely" initiative. CONCLUSIONS: Low value surgical practices are perceived as a frequent problem, which requires an approach entailing intervention with patients and the media as well as professionals. Increase awareness on unnecessary surgical practices, and how to avoid them remain essential.

Potential Consequences of Patient Complications for Surgeon Well-being: A Systematic Review

Importance

Patient complications occur in all areas of surgery, and managing them is an important part of surgical practice. Several investigations have examined whether surgeon health affects patient outcomes; however, to date, whether adverse patient outcomes affect surgeon well-being has not been comprehensively examined.

Objective

To examine how surgical complications in their patients affect the health of surgeons, in particular emotional outcomes, coping strategies, and support mechanisms.

Evidence Review

A systematic literature review was conducted to identify studies evaluating how patient complications affect surgeons with the aim of determining emotional outcomes, coping strategies, and support mechanisms. Studies pertaining to burnout alone or not conducted in surgeons were excluded. The databases searched included MEDLINE, Embase, PubMed, Web of Science, and Google Scholar, with all literature available on these data sets until the search date of May 1, 2018; collected data were analyzed between May 2 and June 1, 2018. The reference lists of all included studies, as well as related review articles, were manually searched to identify further relevant studies. An inductive approach was used to identify common themes.

Findings

Nine case series or cross-sectional studies from the United Kingdom or North America were found (8518 unique participants), with 1 study in surgical trainees. Across all studies, surgeons were affected emotionally after complications, with adverse consequences in their professional and personal lives. Four themes were identified within the literature: the adverse emotional influence of complications (anxiety, guilt, sadness, shame, interference with professional and leisure activities) after intraoperative adverse events; coping mechanisms used by surgeons and trainees (limited discussion with colleagues, exercise, artistic or creative outlets, alcohol and substance abuse); institutional support mechanisms and barriers to support (clinical conferences, discussion with mentors, a perception that emotional distress would be perceived as a constitutional weakness); and the consequences of complications in future clinical practice (changes in practice, introduction of protocols, education of staff members, and participating in root-cause analysis).

Conclusions and Relevance

This study's findings suggest that complications affect surgeons adversely across multiple domains. Further efforts are required at a personal, departmental, institutional, and organizational level to provide effective support. This review highlights that the psychological consequences of patient complications seem to be an important occupational health issue for surgeons.

Desdobramentos judiciais do erro na enfermagem

Resumo Objetivo: Caracterizar processos com decisões judiciais por erros envolvendo profissionais de enfermagem. Métodos: Estudo documental, com os casos julgados e concluídos, que versavam sobre erro envolvendo profissionais de enfermagem. O levantamento foi realizado nos meses de maio e junho de 2018, no sítio online do Tribunal de Justiça do Paraná. As informações de interesse foram: local da ocorrência, profissionais envolvidos, características das vítimas, do erro e o desfecho da investigação. Para análise os dados foram submetidos à estatística descritiva. Resultados: Foram identificados 31 casos julgados, cuja maioria ocorreu em ambiente hospitalar (90,32%), com indivíduos adultos (64,71%). Em oito casos a vítima foi a óbito, em metade deles apresentou incapacidade temporária (17=50%) e sete pessoas apresentaram incapacidade permanente. O erro mais frequente envolveu a administração de medicamentos (38,71%), seguido por erro de assistência ao parto (19,35%). Em mais da metade dos casos o boletim de ocorrência foi registrado pela própria vítima (58,06%) e somente um perito médico foi consultado durante o processo (61,29%). Em 22 casos o profissional foi condenado. Destes, 20 foram condenações cíveis e duas criminais. Em média, os processos cíveis geraram ressarcimento de R$ 42.614,30 reais e nos processos criminais, a média de tempo de reclusão, convertidos em serviços comunitários foi de 18 meses. Conclusão: Os processos judiciais culminaram em condenações. Além disso, apontam à necessidade de melhor estrutura e apoio aos profissionais que passam pela experiência jurídica.

A colonized general practice? A critical habermasian analysis of how general practitioners experience defensive medicine in their everyday working life

The aim of this article is to show how Jürgen Habermas' communicative action theory serves as a useful tool in analysing and interpreting empirical data on how Danish general practitioners experience defensive medicine in their everyday working life. Through six qualitative focus group interviews with a total of 28 general practitioners (14 men and 14 women), the general practitioners' understandings of and experiences with defensive medicine were unfolded and discussed. Traditionally, defensive medicine is understood as physicians' deviation from sound medical practice due to fears of liability claims or lawsuits. In this study, however, a broader understanding of defensive medicine emerged as unnecessary medical actions that are more substantiated by feelings of demands and pressures than meaningful clinical behaviour. As a first analytical step, the data are contextualized drawing on the medical sociological literature that has theorized recent changes within primary health care such as regulation, audit, standardization and consumerism. Using Habermas' theorization to further interpret the general practitioners' experiences, we argue that central areas of the general practitioners' clinical everyday work life can be seen as having become subject to the habermasian social and political processes of 'strategic action' and 'colonization'. It is furthermore shown that the general practitioners share an impulse to resist these colonizing processes, hereby pointing to a need for challenging the increasingly defensive medical culture that seems to pervade the organization of general practice today.

Nurses' families' experiences of involvement in nursing errors: A qualitative study

Background

The most important and irreversible consequence of medical errors is the human impact caused by unintended actions. In a few studies, the significant impact of this error on the private life of healthcare staff have been mentioned, but the problems of the involved nurses' families had been ignored, as of now.

Aims

This study aimed to explain the nurses' families' experiences of involvement in nursing errors.

Methods

This is a qualitative study using conventional content analysis with 20 semi-structured interviews conducted with nurses and family members of nurses involved in medical errors, done through purposeful sampling and willingness to participate in the study.

Results

The results of the data analysis consisted of five main categories including disruption in family functioning, the crisis of fear, oppression, damage, and neglect, along with 15 subcategories.

Conclusion

Considering the effects of nursing errors on the families of nurses involved in the error, such as disruption of family functioning, the family of nurses involved in the error should also be considered and paid attention to. These families are abandoned and the need to promote the culture of supporting the family is tangible.

Physicians' perception of the importance of ethical and deontological issues in a major Italian Province: pilot questionnaire and its validation

BACKGROUND AND AIM

This study aims at validating a questionnaire on physicians' knowledge and perception of deontological and ethical rules that guide the medical profession, in a major Italian Province.

METHODS

We designed an on-line survey questionnaire. Participants (N=200) were asked to fill in information regarding their demographic features and knowledge of the deontological code.

RESULTS

Concerning the preliminary data, the median total score on knowledge of the deontological code was 0.50. A significant difference in the total score was observed among education groups. Specifically, the median total score among subjects with a specialist qualification was significantly lower than among those with only a medical degree.

CONCLUSIONS

The tested instrument and methodology appear to be efficacious and reliable. Our preliminary data indicate that knowledge of the rules concerning medical deontology and the related principles of medical ethics seems to be very limited. Therefore, the authors plan to implement a second phase of the study, which will consist of the questionnaire' distribution to a broader and more representative sample.

Second victims in health care: current perspectives

Medical errors are a serious public health problem and the third-leading cause of death after heart disease and cancer. Every day, the health care professionals (HCPs) practice their skill and knowledge within excessively complex situations and meet unexpected patient outcomes. These unexpected complications and unintentional errors will always be a part of the medical system due to the universal nature of human fallibility and technology. While not all errors are life-threatening, they can significantly compromise a patient's quality of life. However, the victims of medical error reach far beyond the patient. The second victim (SV), which defined for the first time by Albert Wu in his description of the impact of errors on HCPs by both personally and professionally, is a medical emergency equivalent to post-traumatic stress disorder. When the errors occur, it causes a domino effect including the four groups: the patient and family (first victim), the HCP [SV], the hospital reputation (third victim), and patients who are harmed subsequently (fourth victims). The rights of our patients to safe, reliable, and patient-centered care are critical and most important as a primary and utmost aim of medicine. However, we also have to take care of our own (SVs), especially when we have good people who mean to do well and then find themselves in an emotionally complex situation. There is a need to articulate to the public, politicians, and media how system failure leads to medical error even in hand of well-educated and competent HCPs are given an increasing clinical workload. Furthermore, despite several leading institutions in western countries have developed formal support programs that allow HCPs to cope with their emotional distress by obtaining timely support in an emphatic, confidential, non-judgmental environment, we need to raise awareness of this phenomenon and appropriate institutional responses both to harmed patients and their families and HCPs.

Nursing errors in the medication process: television electronic media analysis

Abstract Objective: To analyze the disclosures of a Brazilian television medium about medication errors in nursing. Methods: Documental research based on audiovisual news stories broadcast until December 2016, on the G1 portal and submitted to error type categorization and Bardin's Thematic Content Analysis. Results: A total of 14 cases of medication error were analyzed, including 25 news stories. The majority of them occurred in hospitals (n = 12); including children (n = 7) and older adults (n = 6); and leading to death (n = 10). In the qualitative analysis, two thematic categories emerged: (1) Identification of medication errors and Reaction of those (allegedly) involved and (2) Reactions, feelings and attitudes towards medication errors. Conclusion and implications for practice: The news stories show the apparent culpability of individuals and do not address the mechanisms and flawed processes that may have triggered errors. Risk management must be associated with academic and professional discussions, with greater public awareness of patient safety.

How is defensive medicine understood and experienced in a primary care setting? A qualitative focus group study among Danish general practitioners

OBJECTIVES

Recent years have witnessed a progressive increase in defensive medicine (DM) in several Western welfare countries. In Danish primary and secondary care, documentation on the extent of DM is lacking. Before investigating the extent of DM, we wanted to explore how the phenomenon is understood and experienced in the context of general practice in Denmark. The objective of the study was to describe the phenomenon of DM as understood and experienced by Danish general practitioners (GPs).

DESIGN

A qualitative methodology was employed and data were generated through six focus group interviews with three to eight GPs per group (n=28) recruited from the Region of Southern Denmark. Data were analysed using a thematic content analysis inspired by a hermeneutic-phenomenological focus on understanding and meaning.

RESULTS

DM is understood as unnecessary and meaningless medical actions, carried out mainly because of external demands that run counter to the GP's professionalism. Several sources of pressure to act defensively were identified by the GPs: the system's pressure to meet external regulations, demands from consumerist patients and a culture among GPs and peers of infallibility and zero-risk tolerance.

CONCLUSIONS

GPs understand DM as unnecessary and meaningless actions driven by external demands instead of a focus on the patient's problem. GPs consider defensive actions to be carried out as a result of succumbing to various sources of pressure deriving from the system, the patients, the GPs themselves and peers.

Clinical safety and professional liability claims in Ophthalmology

INTRODUCTION

Patient safety is an international public health priority. Ophthalmology scientific societies and organisations have intensified their efforts in this field. As a tool to learn from errors, these efforts have been linked to the management of medical professional liability insurance through the analysis of claims.

MATERIAL AND METHODS

A review is performed on the improvements in patient safety, as well as professional liability issues in Ophthalmology.

RESULTS

There is a high frequency of claims and risk of economic reparation of damage in the event of a claim in Ophthalmology. Special complaints, such as wrong surgery or lack of information, have a high risk of financial compensation and need strong efforts to prevent these potentially avoidable events. Studies focused on pathologies or specific procedures provide information of special interest to sub-specialists. The specialist in Ophthalmology, like any other doctor, is subject to the current legal provisions and appropriate mandatory training in the medical-legal aspects of health care is essential.

CONCLUSIONS

Professionals must be aware of the fundamental aspects of medical professional liability, as well as specific aspects, such as defensive medicine and clinical safety. The understanding of these medical-legal aspects in the routine clinical practice can help to pave the way towards a satisfactory and safe professional career, and help in increasing patient safety. The aim of this review is to contribute to this training, for the benefit of professionals and patients.

Prevalence and costs of defensive medicine: a national survey of Italian physicians

Objective To identify the prevalence of the practice of defensive medicine among Italian hospital physicians, its costs and the reasons for practising defensive medicine and possible solutions to reduce the practice of defensive medicine. Methods Cross-sectional web survey. Main outcome measures Number of physicians reporting having engaged in any defensive medicine behaviour in the previous year. Results A total of 1313 physicians completed the survey. Ninety-five per cent believed that defensive medicine would increase in the near future. The practice of defensive medicine accounted for approximately 10% of total annual Italian national health expenditure. Conclusions Defensive medicine is a significant factor in health care costs without adding any benefit to patients. The economic burden of defensive medicine on health care systems should provide a substantial stimulus for a prompt review of this situation in a time of economic crisis. Malpractice reform, together with a systematic use of evidence-based clinical guidelines, is likely to be the most effective way to reduce defensive medicine.

Validation of the German version of two scales (RIS, RCS-HCP) for measuring regret associated with providing healthcare

BACKGROUND

The regret intensity scale (RIS) and the regret coping scale for healthcare professionals (RCS-HCP) working in hospitals assess the experience of care-related regrets and how healthcare professional deal with these negative events. The aim of this study was to validate a German version of the RIS and the RCS-HCP.

METHODS

The RIS and RCS-HCP in German were first translated into German (forward- and backward translations) and then pretested with 16 German-speaking healthcare professionals. Finally, two surveys (test and 1-month retest) administered the scales to a large sample of healthcare professionals from two different hospitals.

RESULTS

Of the 2142 eligible healthcare professionals, 494 (23.1%) individuals (108 physicians) completed the cross-sectional web based survey and 244 completed the retest questionnaire. Participants (n = 165, 33.4% of the total sample) who reported not having experienced a regret in the last 5 years, had significantly more days of sick leave during the last 6 months. These participants were excluded from the subsequent analyses. The structure of the scales was similar to the French version with a single dimension for the regret intensity scale (Cronbach's alpha: 0.88) and three types of coping strategies for the regret coping scale (alphas: 0.69 for problem-focused strategies, 0.67 for adaptive strategies and 0.86 for the maladaptive strategies). Construct validity was good and reproduced the findings of the French study, namely that higher regret intensity was associated with situations that entailed more consequences for the patients. Furthermore, higher regret intensity and more frequent use of maladaptive strategies were associated with more sleep difficulties and less work satisfaction.

CONCLUSIONS

The German RIS and RCS-HCP scales were found valid for measuring regret intensity and regret coping in a population of healthcare professionals working in a hospital. Reporting no regret, which corresponds to the coping strategy of suppression, seems to be a maladaptive strategy because it was associated with more frequent sick day leaves.

Cross-sectional survey on defensive practices and defensive behaviours among Israeli psychiatrists

OBJECTIVE

Psychiatry is a low-risk specialisation; however, there is a steady increase in malpractice claims against psychiatrists. Defensive psychiatry (DP) refers to any action undertaken by a psychiatrist to avoid malpractice liability that is not for the sole benefit of the patient's mental health and well-being. The objectives of this study were to assess the scope of DP practised by psychiatrists and to understand whether awareness of DP correlated with defensive behaviours.

METHODS

A questionnaire was administered to 213 Israeli psychiatry residents and certified psychiatrists during May and June 2015 regarding demographic data and experience with malpractice claims, medicolegal literature and litigation. Four clinical scenarios represented defensive behaviours and reactions (feelings and actions) to malpractice claims.

RESULTS

Forty-four (20.6%) certified psychiatrists and four (1.9%) residents were directly involved in malpractice claims, while 132 (62.1%) participants admitted to practising DP. Residents acknowledged the practice of DP more than did senior psychiatrists (p=0.038).Awareness of DP correlated with unnecessary hospitalisation of suicidal patients, increased unnecessary follow-up visits and prescribing smaller drug dosages than required for pregnant women and elderly patients.

CONCLUSIONS

This study provides evidence that DP is well established in the routine clinical daily practice of psychiatrists. Further studies are needed to reveal whether DP effectively protects psychiatrists from malpractice suits or, rather, if it impedes providing quality psychiatric care and represents an economic burden that leads to more harm for the patient.

Perinatal Nurses Reported to Boards of Nursing: Understanding the Facts

Today's healthcare system is in a state of transformation, as changes in technology, diagnostic approaches, treatments, and levels of professional practice occur on a regular basis. Nurses continue to be the most trusted profession. What has not changed in clinical practice is the amount of responsibility and level of accountability. Therefore, nurses are morally, legally, and ethically responsible for nursing judgment and clinical-based actions covered under each state's Nurse Practice Act, the American Nurses Association's core principles, and position statements as well as standard setting documents from professional organizations. Unfortunately, mistakes happen in an enormous system where human error cannot be entirely avoided, which is why being named in a board of nursing complaint can be so devastating. Stress and accusations of not providing reasonable or prudent care can be overwhelming, which may impact a perinatal clinician's health. This article's purpose is to provide information about the process of a board of nursing complaint, potential sequelae of an investigation, as well as best practices to decrease risk, focusing exclusively on perinatal nurses and advanced practice providers.

Addressing the misdiagnosis of asthma in adults: where does it go wrong?

INTRODUCTION

Asthma is diagnosed based on patients' respiratory symptoms of wheeze, cough, chest tightness and/or dyspnea together with physiologic evidence of variable and reversible expiratory airflow limitation. A high prevalence of overdiagnosis, underdiagnosis and misdiagnosis of adult asthma has been reported in the literature. Areas covered: Misdiagnosis of asthma in adults can occur in the community due to physicians' failure to confirm airflow limitation using spirometry, the relatively poor sensitivity of spirometry to absolutely rule in asthma, the complexity of multiple asthma phenotypes and endotypes, and the inherent day to day variability of asthma symptoms and airflow limitation. Consequences of asthma misdiagnosis to the patient and to the healthcare system include increased medication costs, increased potential side effects related to unnecessary use of medications and lost opportunities to diagnose the true cause of patients' respiratory symptoms. Expert commentary: Here we provide a review of the problem of misdiagnosis of adult asthma and suggestions for how to decrease the risk of misdiagnosis.

The determinants of defensive medicine in Italian hospitals: The impact of being a second victim

BACKGROUND

Defensive medicine affects healthcare systems worldwide. The concerns and perception about medical liability could lead practitioners to practise defensive medicine. Second victim is a healthcare worker involved in an unanticipated adverse patient event. The role of being second victim and the other possible determinants for defensive medicine is mostly unclear.

OBJECTIVE

To study the condition of being second victim as a possible determinants of defensive medicine among Italian hospital physicians.

DESIGN, SETTING AND PARTICIPANTS

A secondary analysis of the database of the national survey study on the prevalence and the costs of defensive medicine in Italy that was carried out between April 2014 and June 2014 in 55 Italian hospitals was performed for this study. The demographic section of the questionnaire was selected including the physician's age, gender, specialty, activity volume, grade and the variable being a second victim after an adverse event.

RESULTS

A total sample of 1313 physicians (87.5% response rate) was used in the data analyses. Characteristics of the participants included a mean age 49.2 of years and 19.4 average years of experience. The most prominent predictor for practising defensive medicine was the physicians' experience of being a second victim after an adverse event (OR=1.88; 95%CI, 1.38-2.57). Other determinants included age, years of experience, activity volume and risk of specialty.

CONCLUSIONS

Malpractice reform, effective support to second victims in hospitals together with a systematic use of evidence-based clinical guidelines, emerged as possible recommendations for reducing defensive medicine.