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ISQua Fellowship Forum

Patient Safety: Support for The Second Victim

Phil Hassen, President of the Canadian Network for International Surgery; ISQua Fellowship Forum Moderator.


March 2017

Devastated. Unraveled. Traumatized. These words describe the possible impact medical errors can have on healthcare providers.

The terribly tragic consequences for all involved in a serious medical error is perhaps best underscored in the example of a Critical Care nurse of Seattle Children's Hospital who accidentally gave a sick baby a fatal dose of medicine and then later took her own life in the wake of the tragedy. On September 14, 2010, Kimberly Hiatt accidentally overdosed a baby with ten times too much Calcium Chloride. The medication error is reported to have "led to the unraveling of her life which caused not only the death of the eight-month-old child but her dismissal, firing and then suicide at aged 50."(1)

The phrase, "second victims" introduced by Dr. Wu, a professor of health policy and management at the John Hopkins Bloomberg School of Public Health describes physicians’ significant emotional reactions and long lasting distress in the aftermath of an error.(2) When a physician or any other health care provider does harm and the outcome negatively affects a patient’s health and/or quality of life, then the error can have a devastating impact on the patient and also can place the provider at risk of significant emotional distress. Thus Dr. Wu defines “second victims” as “health care providers who are involved with patient adverse events and who subsequently have difficulty coping with their emotions”.

Human error can and does happen more often than we would like as we provide care and services to patients. Patient safety has been the focus of health care organizations for the last 15 years plus and much of our attention – rightfully so – has been on the patient who is harmed and the family, and how to mitigate, minimize or eliminate errors.

And as we know an incident causing harm is most often accidental and unintentional. This is in most part because care systems can be fragmented; clinical practice guidelines are not advanced and/or continuously improved; among others identified in the literature. Given the complexity of healthcare/medical care organizations where liability claims arise, where health care delivery systems includes multiple hand-offs with any number of providers and where employee performance evaluations have cited harm done , it presents a difficult climate for care providers to seek support. Now, it is important to put in place better support systems for care providers for what has been cited as second victims experiencing something similar to post traumatic stress disorder.

Approaches to Support Second Victims

In a critical review of the literature Schwappach and Boluarte conclude that many professionals respond to error with serious emotional distress and these reactions can imprint an emotional scar. Given the traumatizing effect, healthcare organizations and leaders have to "take accountability and provide staff with formal and informal systems of support."(3) Assisting care providers with trauma that results from their involvement in medical error is an evolving field of expertise and program development. In studies reviewed by Schwappach and Boluarte a very high percentage of physicians report that health care organizations provide inadequate support in coping with stress associated with medical error.

However, there are alternative solutions being developed to assist care providers by some hospitals and health care organizations. First it is vital to acknowledge the emotional impact and determine the type and nature of trauma to any staff member arising from an adverse event. Then to put in place support resources for those affected such as:

• Staff support or assistance programs, pastoral care services and other means to discuss the incidents without blame. These may be difficult to establish but are a requirement; especially developing support programs tailored for physicians.
• Use of established Morbidity and Mortality Rounds which focus on adverse events. It takes very strong leadership to shift the dialogue about patient adverse events so that it is without blame or repercussion and to establish a supportive learning environment.
• Formal and informal patient safety educational programs enabling positive cultural change.

In summary, a patient safety culture which is characterized by communications founded on mutual trust and learning --- including disclosure --- while difficult to achieve is essential for the patients, families and healthcare providers. As stated by Dr. Donald Berwick, former Chief Executive Officer, Healthcare Improvement, Boston, "... everyone benefits from transparency. Both the safety of our patients and the satisfaction of our workers require an open and non-punitive environment where information is freely shared and responsibility broadly accepted."(4)

In closing, some health care/hospital systems have recognized the severe consequences to staff, physicians and other care providers alike – and the dire need to support health care workers who are traumatically affected by medical error. It is important to understand the severe emotional consequences on second victims, and put in place systematic structures which support our vitally important resource of staff and physicians who have been traumatized by harm done to a patient --- these people are our friends and colleagues.

Patient Safety: Support for the Second Victim Questions for Discussion

1. Have you ever made a medical error followed by a significant personal emotional reaction or distress? If so, what support did you receive? What was helpful and what were some of the barriers?

2. Have you ever known anyone else who you would say was a second victim?
• What insight did you gain from this experience?
• What support did you offer?
• What are some approaches you would take in designing a system of support for second victims given your experience?

3. What are some examples of approaches you are aware of to support health care providers and address the emotional distress associated with their involvement in a medical error?

4. What are some negative dynamics in organizational culture that leaders must challenge and change to improve both patient safety and support to health care providers?

5. Does this Forum in any way, make you rethink your approach to patient safety and associated issues? If so, in what way?

(1) Saavedra Sheena Maireen. Remembering Kimberly Hiatt: A Casualty of Second Victim Syndrome. How a single mistake from an experienced critical care nurse caused her to end her life. https://nurseslabs.com/ Nov 25, 2015.

(2) Wu A.W. Medical error: the second victim. BMJ. 2000; 320 (7237): 726-7.

(3) Schwappach David L.B., Boluarte Till A., The emotional impact of medical error involvement on physicians: a call for leadership and organizational accountability. Swiss Medical Weekly. Early Online Publication, October 14, 2008.

(4) Berwick Donald, Editorial Review. BMJ. March 18, 2000; Volume 320:726



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