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Sells JR, Cole I, Dharmasukrit C, Brown A, Rovinski-Wagner C, Tasseff TL. System planning for modern-day Just Culture to mitigate worker distress and second victim response. BMJ LEADER 2024; 8:149-152. [PMID: 37734904 DOI: 10.1136/leader-2023-000811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Joanna R Sells
- VA Quality Scholars Program, San Francisco VA Health Care System, San Francisco, California, USA
- Rocky Mountain MIRECC, Aurora, Colorado, USA
| | - Irene Cole
- VA Quality Scholars Program, San Francisco VA Health Care System, San Francisco, California, USA
- School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - Charlie Dharmasukrit
- VA Quality Scholars Program, San Francisco VA Health Care System, San Francisco, California, USA
- Center for Nursing Excellence and Innovation, UCSF Health, San Francisco, California, USA
| | - Amy Brown
- VA Readjustment Counseling Service, District 3, St. Louis, Missouri, USA
- VA Quality Scholars Program, Iowa City VA Medical Center, Iowa City, Iowa, USA
| | - Christine Rovinski-Wagner
- Office of Integrated Veteran Care, VA Health Connect, Veterans Health Administration, Washington, DC, USA
- VA Quality Scholars Program, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Tamara L Tasseff
- VA Quality Scholars Program, Iowa City VA Medical Center, Iowa City, Iowa, USA
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Copley DJ, Burchill CN, Lindell D, Dolansky MA. Second Victim Phenomenon Educational Program Evaluation. J Nurses Prof Dev 2024; 40:10-15. [PMID: 37812129 DOI: 10.1097/nnd.0000000000000978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Second victim phenomenon (SVP) occurs when nurses who are involved in an unanticipated adverse event become victimized and traumatized by the event. Following a needs assessment, an SVP education program was implemented, including adverse events and SVP experiences, available support, and a case study. Evaluation indicated nurses had improved knowledge and attitude and increased practice intent. Education that promotes awareness is the first step to support nurses who experience events that can precipitate SVP.
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Seys D, Panella M, Russotto S, Strametz R, Joaquín Mira J, Van Wilder A, Godderis L, Vanhaecht K. In search of an international multidimensional action plan for second victim support: a narrative review. BMC Health Serv Res 2023; 23:816. [PMID: 37525127 PMCID: PMC10391912 DOI: 10.1186/s12913-023-09637-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/03/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Insights around second victims (SV) and patient safety has been growing over time. An overview of the available evidence is lacking. This review aims to describe (i) the impact a patient safety incident can have and (ii) how healthcare professionals can be supported in the aftermath of a patient safety incident. METHODS A literature search in Medline, EMBASE and CINAHL was performed between 1 and 2010 and 26 November 2020 with studies on SV as inclusion criteria. To be included in this review the studies must include healthcare professionals involved in the aftermath of a patient safety incident. RESULTS In total 104 studies were included. SVs can suffer from both psychosocial (negative and positive), professional and physical reactions. Support can be provided at five levels. The first level is prevention (on individual and organizational level) referring to measures taken before a patient safety incident happens. The other four levels focus on providing support in the aftermath of a patient safety incident, such as self-care of individuals and/or team, support by peers and triage, structured support by an expert in the field (professional support) and structured clinical support. CONCLUSION The impact of a patient safety incident on healthcare professionals is broad and diverse. Support programs should be organized at five levels, starting with preventive actions followed by self-care, support by peers, structured professional support and clinical support. This multilevel approach can now be translated in different countries, networks and organizations based on their own culture, support history, structure and legal context. Next to this, they should also include the stage of recovery in which the healthcare professional is located in.
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Affiliation(s)
- Deborah Seys
- Department Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, Leuven, Belgium.
- Department Public Health and Primary Care, KU Leuven, Leuven, Belgium.
| | - Massimiliano Panella
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Sophia Russotto
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | | | - José Joaquín Mira
- The Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Alicante, Spain
- Health Psychology Department, Miguel Hernandez University, Elche, Spain
| | - Astrid Van Wilder
- Department Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Lode Godderis
- Department Public Health and Primary Care, KU Leuven, Leuven, Belgium
- External Service for Prevention and Protection at Work, IDEWE, Heverlee, Belgium
| | - Kris Vanhaecht
- Department Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Department of Quality, University Hospitals Leuven, 3000, Leuven, Belgium
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Sahay A, McKenna L. Nurses and nursing students as second victims: A scoping review. Nurs Outlook 2023; 71:101992. [PMID: 37302259 DOI: 10.1016/j.outlook.2023.101992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Second victim describes the impact on health care professionals after an error causing preventable patient harm. However, to date, the impact of making errors in practice by nurses and/or nursing students is unclear. PURPOSE To describe and understand what is known about nurses and nursing students as second victims. METHODS A scoping review was completed using three databases: CINAHL, Medline, and Proquest for the period between 2010 and 2022. A total of 23 papers underwent thematic analysis. DISCUSSION Three themes were identified: (a) Psychological distress and symptomatology, (b) Coping-response/reactions to errors, and (c) Seeking support and understanding. CONCLUSION Nurses and nursing students' well-being and productivity levels can be negatively affected by inadequate team and organisational support. To improve team functioning, appropriate support mechanisms must be implemented to assist nurses who experience significant distress after making errors. Nursing leadership should prioritise improving support programs, assessing workload allocation, and increasing awareness amongst leaders of the potential benefits of providing support to second victims.
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Affiliation(s)
- Ashlyn Sahay
- School of Nursing and Midwifery, Central Queensland University, Mackay, QLD, Australia.
| | - Lisa McKenna
- School of Nursing and Midwifery, La Trobe University, Bundoora, VIC, Australia.
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Park J, You SB, Kim H, Park C, Ryu GW, Kwon S, Kim Y, Lee S, Lee K. Experience of Nurses with Intravenous Fluid Monitoring for Patient Safety: A Qualitative Descriptive Study. Risk Manag Healthc Policy 2022; 15:1783-1793. [PMID: 36171867 PMCID: PMC9512022 DOI: 10.2147/rmhp.s374563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/12/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose Medication administration is a complex process and constitutes a substantial component of nursing practice that is closely linked to patient safety. Although intravenous fluid administration is one of the most frequently performed nursing tasks, nurses’ experiences with intravenous rate control have not been adequately studied. This study aimed to explore nurses’ experiences with infusion nursing practice to identify insights that could be used in interventions to promote safe medication administration. Patients and methods This qualitative descriptive study used focus group interviews of 20 registered nurses who frequently administered medications in tertiary hospitals in South Korea. Data were collected through five semi-structured focus group interviews, with four nurses participating in each interview. We conducted inductive and deductive content analysis based on the 11 key topics of patient safety identified by the World Health Organization. Reporting followed the consolidated criteria for reporting qualitative research (COREQ) checklist. Results Participants administered infusions in emergency rooms, general wards, and intensive care units, including patients ranging from children to older adults. Two central themes were revealed: human factors and systems. Human factors consisted of two sub-themes including individuals and team players, while systems encompassed three sub-themes including institutional policy, culture, and equipment. Conclusion This study found that nurses experienced high levels of stress when administering infusions in the correct dose and rate for patient safety. Administering and monitoring infusions were complicated because nursing processes interplay with human and system factors. Future research is needed to develop nursing interventions that include human and system factors to promote patient safety by reducing infusion-related errors.
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Affiliation(s)
- Jeongok Park
- Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, Seoul, South Korea
| | - Sang Bin You
- Yonsei University College of Nursing, Seoul, South Korea
| | - Hyejin Kim
- Severance Hospital, Yonsei University Health System, Seoul, South Korea
| | - Cheolmin Park
- Department of Materials Science and Engineering, Yonsei University, Seoul, South Korea
| | - Gi Wook Ryu
- Department of Nursing, Hansei University, Gunpo-si, South Korea
| | - Seongae Kwon
- Yonsei University College of Nursing, Seoul, South Korea
| | - Youngkyung Kim
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, South Korea
| | - Sejeong Lee
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, South Korea
| | - Kayoung Lee
- Gachon University College of Nursing, Incheon, South Korea
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Harrison R, Johnson J, McMullan RD, Pervaz-Iqbal M, Chitkara U, Mears S, Shapiro J, Lawton R. Toward Constructive Change After Making a Medical Error: Recovery From Situations of Error Theory as a Psychosocial Model for Clinician Recovery. J Patient Saf 2022; 18:587-604. [PMID: 35617626 PMCID: PMC9422758 DOI: 10.1097/pts.0000000000001038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Making a medical error is a uniquely challenging psychosocial experience for clinicians. Feelings of personal responsibility, coupled with distress regarding potential or actual patient harm resulting from a mistake, create a dual burden. Over the past 20 years, experiential accounts of making an error have provided evidence of the associated distress and impacts. However, theory-based psychosocial support interventions to improve both individual outcomes for the involved clinicians and system-level outcomes, such as patient safety and workforce retention, are lacking. There is a need for evidence-based ways to both structure and evaluate interventions to decrease the distress of making a medical error and its impacts. Such interventions play a role within wider programs of health professional support. We sought to address this by developing a testable, psychosocial model of clinician recovery after error based on recent evidence. METHODS Systematic review methodology was used to identify studies published between January 2010 and June 2021 reporting experiences of direct involvement in medical errors and/or subsequent recovery. A narrative synthesis was produced from the resulting articles and used as the basis for a team-based qualitative approach to model building. RESULTS We identified 25 studies eligible for inclusion, reporting evidence primarily from experiences of doctors and nurses. The identified evidence indicates that coping approach, conversations (whether they occur and whether they are perceived to be helpful or unhelpful), and learning or development activities (helpful, unhelpful or absent) may influence the relationship between making an error and both individual clinician outcomes of emotional impact and resultant practice change. Our findings led to the development of the Recovery from Situations of Error Theory model, which provides a preliminary theoretical basis for intervention development and testing. CONCLUSIONS The Recovery from Situations of Error Theory model is the first testable psychosocial model of clinician recovery after making a medical error. Applying this model provides a basis to both structure and evaluate interventions to decrease the distress of making a medical error and its impacts and to support the replication of interventions that work across services and health systems toward constructive change. Such interventions may be embedded into the growing body of peer support and employee support programs internationally that address a diverse range of stressful workplace experiences.
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Affiliation(s)
- Reema Harrison
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Judith Johnson
- School of Psychology, University of Leeds, Leeds
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, United Kingdom
| | - Ryan D. McMullan
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Maha Pervaz-Iqbal
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Upma Chitkara
- Hunter New England Medical Libraya, New Lambton, Australia
| | - Steve Mears
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Jo Shapiro
- Department of Anesthesia, Pain and Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Rebecca Lawton
- Institute of Psychological Sciences, University of Leeds, Leeds, United Kingdom
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Kappes M, Romero-García M, Delgado-Hito P. Coping strategies in health care providers as second victims: A systematic review. Int Nurs Rev 2021; 68:471-481. [PMID: 34118061 DOI: 10.1111/inr.12694] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 02/05/2021] [Accepted: 05/04/2021] [Indexed: 01/16/2023]
Abstract
AIM To analyze personal and organizational strategies described in the literature for dealing with the second victim phenomenon among healthcare providers. BACKGROUND The second victim phenomenon involves many associated signs and symptoms, which can be physical, psychological, emotional, or behavioral. Personal and organizational strategies have been developed to deal with this phenomenon. MATERIALS AND METHODS A systematic review was carried out in PubMed, Cochrane Library, Web of Science, Scopus, PsycINFO, Science Direct, and Cumulative Index to Nursing and Allied Health Literature databases, searching for evidence published between 2010 and 2019 in Spanish, English, German, and Portuguese. RESULTS Seven hundred and eighty-three articles were identified. After eliminating duplicates, applying inclusion and exclusion criteria and critical analysis tools of the Joanna Briggs Institute, 16 research articles were included: 10 quantitative studies (design: descriptive, correlational, systematic, or integrative review) and six qualitative studies (descriptive, systematic review). There are several different personal and organizational strategies for dealing with the second victim phenomenon. Among these, peer support and learning from adverse events are highly valued. In personal strategies stands out the internal analysis of the adverse event that the professional performs to deal with the generated negative feelings. In organizational strategies, the most valued are second victim support programs with rapid response teams and made up of peers. CONCLUSIONS The main organizational coping strategies for tackling this phenomenon are online programs in countries such as the United States, Spain, and other European countries. Formal evaluation of these programs and research is required in Latin America. IMPLICATIONS FOR NURSING AND HEALTH POLICIES Adequately coping with the second victim phenomenon allows health professionals and organizations to learn from adverse events. Furthermore, by supporting health professionals who suffer from the second victim phenomenon, the organization takes care of its most valuable resource, its human capital. This contributes toward building a culture of healthcare quality in organizations, which will reduce adverse events in the future.
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Affiliation(s)
- Maria Kappes
- Faculty of Healthcare Sciences, Nursing School, Universidad San Sebastián, Puerto Montt, Chile
| | - Marta Romero-García
- Fundamental Care and Medical-Surgical Nursing Department, School of Nursing, L'Hospitalet de Llobregat, University of Barcelona, Barcelona, Spain.,IDIBELL, L'Hospitalet de Llobregat, Bellvitge Biomedical Research Institute, Barcelona, Spain.,Collado Villalba, International Research Project-Proyecto HU-CI, Madrid, Spain
| | - Pilar Delgado-Hito
- Fundamental Care and Medical-Surgical Nursing Department, School of Nursing, L'Hospitalet de Llobregat, University of Barcelona, Barcelona, Spain.,IDIBELL, L'Hospitalet de Llobregat, Bellvitge Biomedical Research Institute, Barcelona, Spain.,Collado Villalba, International Research Project-Proyecto HU-CI, Madrid, Spain
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Quadrado ERS, Tronchin DMR, Maia FDOM. Strategies to support health professionals in the condition of second victim: scoping review. Rev Esc Enferm USP 2021; 55:e03669. [PMID: 33886900 DOI: 10.1590/s1980-220x2019011803669] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 05/15/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To map and analyze the knowledge produced about strategies aimed at promoting support to health professionals in the condition of second victim. METHOD Scoping review, developed in portals, databases and academic websites, whose inclusion criteria were articles and materials indexed in the respective search sites, between January 2000 and December 2019, in Portuguese, English and Spanish. The findings were summarized and analyzed based on descriptive statistics and narrative synthesis. RESULTS A total of 64 studies were included, 100% international; 92.2% in English and 50% from secondary research. The support strategies were grouped into four categories and most of the studies referred to the use of the forYOU, Medically Induced Trauma Support Services and Resilience in Stressful Events programs and the interventions represented, through dialogue with peers, family, friends and managers. CONCLUSION Support strategies for the second victim are pointed out in international studies and mostly developed through programs/services and interventions. It is recommended to develop studies to learn about the phenomenon and to structure feasible support strategies in Brazilian health organizations.
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Affiliation(s)
- Ellen Regina Sevilla Quadrado
- Universidade de São Paulo, Escola de Enfermagem, Programa de Pós-Graduação em Gerenciamento em Enfermagem, São Paulo, SP, Brazil
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Karius DL, Colvin CM. Managing Chemotherapy Extravasation Across Transitions of Care: A Clinical Nurse Specialist Initiative. JOURNAL OF INFUSION NURSING 2021; 44:14-20. [PMID: 33394869 DOI: 10.1097/nan.0000000000000411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Chemotherapy extravasation can lead to serious patient harm in patients with cancer. For nurses who administer vesicant chemotherapy, extravasation is a primary concern. Regardless of nurse experience level and despite prevention strategies, extravasations occur. Literature related to nurse management of chemotherapy extravasation beyond initial treatment is lacking, and no descriptors are available for a formalized process. Communication gaps and a lack of standardized follow-up within a 1400-bed, quaternary care academic medical institution contributes to challenges in care continuity when patients transition between hospital and ambulatory settings. With chemotherapy extravasation, the site does not immediately exhibit signs of tissue injury, leading to a false sense of security. As a result, tissue damage can be significant by the time the patient returns for his or her regular appointment. Two oncology clinical nurse specialists (CNSs) recognized an opportunity to bridge the gap and overcome the challenges by addressing patient needs postextravasation. Between 2015 and 2016, a formal consult process was designed, approved, and implemented to observe, manage, and make recommendations for timely care and follow-up. Since implementation of the process, the oncology CNSs have received multiple requests for consultations. Nursing staff report increased comfort levels with this process in place. A formalized process for managing chemotherapy extravasations increases patient safety and patient and nurse satisfaction.
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Affiliation(s)
- Diana L Karius
- Cleveland Clinic, Cleveland, Ohio
- Diana L. Karius, MS, APRN, CNS, AOCN® , is a clinical nurse specialist in hematology and oncology at Cleveland Clinic. A member of the Oncology Nursing Society (ONS), she has presented nationally at ONS Annual Congress and Infusion Nurses Society (INS) National Academy Conference. She has published and presented on a variety of topics, such as improving chemotherapy safety, pain management, delirium, and palliative care. Ms Karius is also the recipient of the 2011 ONS Excellence in Cancer Nursing Education Award. Karius entered the profession of nursing in 1979, and her extensive career includes health care organizations such as the College of Nursing at Valparaiso University, the University of Chicago Medical Center, University Hospital Home Care in Cleveland, and the Cleveland Clinic Taussig Cancer Institute. Throughout her career she has worked as a clinical teaching assistant, research clinical specialist, case manager, and oncology clinical nurse specialist. With research and evidence-based practice at the forefront of her patient care philosophy, Karius is a member of several national and local industry associations, has served as a publication content reviewer, and is a well-versed presenter. She has also taught as an adjunct faculty member at 3 Northeast Ohio schools of nursing
- Christina M. Colvin, MSN, APRN, AOCNS®, CRNI® , is a clinical nurse specialist in hematology and oncology at Cleveland Clinic. A member of ONS and INS, she has published on topics concerning nurses' safe handling of chemotherapy drugs and care of patients undergoing cancer treatment. Ms Colvin has presented nationally at the INS National Academy Conference
| | - Christina M Colvin
- Cleveland Clinic, Cleveland, Ohio
- Diana L. Karius, MS, APRN, CNS, AOCN® , is a clinical nurse specialist in hematology and oncology at Cleveland Clinic. A member of the Oncology Nursing Society (ONS), she has presented nationally at ONS Annual Congress and Infusion Nurses Society (INS) National Academy Conference. She has published and presented on a variety of topics, such as improving chemotherapy safety, pain management, delirium, and palliative care. Ms Karius is also the recipient of the 2011 ONS Excellence in Cancer Nursing Education Award. Karius entered the profession of nursing in 1979, and her extensive career includes health care organizations such as the College of Nursing at Valparaiso University, the University of Chicago Medical Center, University Hospital Home Care in Cleveland, and the Cleveland Clinic Taussig Cancer Institute. Throughout her career she has worked as a clinical teaching assistant, research clinical specialist, case manager, and oncology clinical nurse specialist. With research and evidence-based practice at the forefront of her patient care philosophy, Karius is a member of several national and local industry associations, has served as a publication content reviewer, and is a well-versed presenter. She has also taught as an adjunct faculty member at 3 Northeast Ohio schools of nursing
- Christina M. Colvin, MSN, APRN, AOCNS®, CRNI® , is a clinical nurse specialist in hematology and oncology at Cleveland Clinic. A member of ONS and INS, she has published on topics concerning nurses' safe handling of chemotherapy drugs and care of patients undergoing cancer treatment. Ms Colvin has presented nationally at the INS National Academy Conference
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Abstract
BACKGROUND Medication errors, now thought to be 4 times greater than previous estimates, harm patients, families, health care institutions, and nurses themselves, who are second victims of their mistakes. PROBLEM Current nursing education may lack coherent medication safety frameworks other than the classic Five Rights construct. APPROACH This project piloted an educational intervention with senior associate degree nursing students based on high-reliability organization (HRO) safety principles. OUTCOMES Subjects evaluated the HRO safety concepts learning experience positively and improved pretest to posttest scores by 74%. CONCLUSIONS This study demonstrates subjects' ready acceptance and comprehension of HRO safety theory as applied to medication safety, an alternative to the Five Rights construct.
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Liukka M, Steven A, Vizcaya Moreno MF, Sara-aho AM, Khakurel J, Pearson P, Turunen H, Tella S. Action after Adverse Events in Healthcare: An Integrative Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17134717. [PMID: 32630041 PMCID: PMC7369881 DOI: 10.3390/ijerph17134717] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 12/04/2022]
Abstract
Adverse events are common in healthcare. Three types of victims of patient-related adverse events can be identified. The first type includes patients and their families, the second type includes healthcare professionals involved in an adverse event and the third type includes healthcare organisations in which an adverse event occurs. The purpose of this integrative review is to synthesise knowledge, theory and evidence regarding action after adverse events, based on literature published in the last ten years (2009–2018). In the studies critically evaluated (n = 25), key themes emerged relating to the first, second and third victim elements. The first victim elements comprise attention to revealing an adverse event, communication after an event, first victim support and complete apology. The second victim elements include second victim support types and services, coping strategies, professional changes after adverse events and learning about adverse event phenomena. The third victim elements consist of organisational action after adverse events, strategy, infrastructure and training and open communication about adverse events. There is a lack of comprehensive models for action after adverse events. This requires understanding of the phenomenon along with ambition to manage adverse events as a whole. When an adverse event is identified and a concern expressed, systematic damage preventing and ameliorating actions should be immediately launched. System-wide development is needed.
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Affiliation(s)
- Mari Liukka
- Department of Nursing Science/Faculty of Health Sciences, University of Eastern Finland, 70211 Kuopio, Finland; (H.T.); (S.T.)
- South Karelia Social and Health Care District, 53130 Lappeenranta, Finland
- Correspondence: ; Tel.: +358-44-791-4871
| | - Alison Steven
- Department of Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne NE7 7XA, UK; (A.S.); (P.P.)
| | | | - Arja M Sara-aho
- Faculty of Health Care & Social Services, LAB University of Applied Sciences, 53850 Lappeenranta, Finland;
| | - Jayden Khakurel
- Research Center for Child Psychiatry, University of Turku, 20500 Turku, Finland;
| | - Pauline Pearson
- Department of Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne NE7 7XA, UK; (A.S.); (P.P.)
| | - Hannele Turunen
- Department of Nursing Science/Faculty of Health Sciences, University of Eastern Finland, 70211 Kuopio, Finland; (H.T.); (S.T.)
- Clinical Development, Education and Research Unit of Nursing (CDERUN), Kuopio University Hospital, 70210 Kuopio, Finland
| | - Susanna Tella
- Department of Nursing Science/Faculty of Health Sciences, University of Eastern Finland, 70211 Kuopio, Finland; (H.T.); (S.T.)
- Faculty of Health Care & Social Services, LAB University of Applied Sciences, 53850 Lappeenranta, Finland;
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Stovall M, Hansen L, Ryn M. A Critical Review: Moral Injury in Nurses in the Aftermath of a Patient Safety Incident. J Nurs Scholarsh 2020; 52:320-328. [DOI: 10.1111/jnu.12551] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Mady Stovall
- Delta Alpha at Large PhD Student Oregon Health & Science University School of Nursing Portland OR USA
| | - Lissi Hansen
- Beta Psi Professor Oregon Health & Science University School of Nursing Portland OR USA
| | - Michelle Ryn
- Professor Oregon Health & Science University School of Nursing Portland OR USA
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Mitzman J, Jones C, McNamara S, Stobart-Gallagher M, King A. Curated Collection for Educators: Five Key Papers About Second Victim Syndrome. Cureus 2019; 11:e4186. [PMID: 31106086 PMCID: PMC6504017 DOI: 10.7759/cureus.4186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Second victim syndrome (SVS) is defined as the psychological or emotional suffering of healthcare workers as a result of a patient adverse, or near miss, event. Initially thought to be related to medical error, we now recognize that SVS can result from a much wider range of circumstances including adverse pediatric patient events, unanticipated deaths, or patients well known to the provider. Residents are particularly susceptible to SVS yet relatively little is written about this topic targeted at their educators. Since educators are positioned to help recognize and guide learners through the experience, this paper targets that reader audience. In this article, we identify and summarize five key papers relevant to educators interested in learning more about SVS as it relates to learners. We identified an extensive list of papers relevant to SVS via online discussions within the Academic Life in Emergency Medicine (ALiEM) Faculty Incubator. The Faculty Incubator is a digital community of practice providing professional development for educators. This list was augmented by an open call on Twitter seen by over 2000 people and yielding a list of 31 papers. We then conducted a three-round modified Delphi process within the authorship group, which included both junior and senior clinician educators, to identify the most impactful papers for educators interested in SVS. The three-round modified Delphi process ranked all papers submitted for review and used iterative rounds to select the five highest-rated papers for inclusion in this article. The group then summarized each of the five papers with specific consideration for junior faculty educators and faculty developers with an interest in SVS in learners. The five papers featured in this article serve as a key reading list for educators across specialties interested in SVS and our commentary provides context for medical educators using the articles.
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Affiliation(s)
- Jennifer Mitzman
- Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Christian Jones
- Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Shannon McNamara
- Emergency Medicine, New York University Langone Medical Center, New York, USA
| | | | - Andrew King
- Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, USA
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Ozeke O, Ozeke V, Coskun O, Budakoglu II. Second victims in health care: current perspectives. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2019; 10:593-603. [PMID: 31496861 PMCID: PMC6697646 DOI: 10.2147/amep.s185912] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/24/2019] [Indexed: 05/13/2023]
Abstract
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.
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Affiliation(s)
- Ozcan Ozeke
- Health Sciences University, Ankara City Hospital, Department of Cardiology, Ankara, Turkey
- Correspondence: Ozcan OzekeSağlık Bilimleri Üniversitesi, Ankara Şehir Hastanesi, Kardiyoloji Klinigi, Ankara06800, TurkiyeTel +90 505 383 6773Email
| | - Vildan Ozeke
- Gaziosmanpasa University, Department of Computer Education and Instructional Technology, Tokat, Turkey
- Gazi University, Department of Medical Education and Informatics, Ankara, Turkey
| | - Ozlem Coskun
- Gazi University, Department of Medical Education and Informatics, Ankara, Turkey
| | - Isil Irem Budakoglu
- Gazi University, Department of Medical Education and Informatics, Ankara, Turkey
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