Patient Safety Tip of the Week
August 9, 2016 More on the Second
Victim
Back in the early 1990’s as we
began dealing with investigations on serious events we recognized that those
healthcare workers involved in serious events, either directly or indirectly,
often had difficulty coping in the aftermath of such events. Albert Wu,
M.D., is generally recognized as coining the term “second victim” to describe
such individuals and their plight (Wu
2000). But while we recognized the issue of the second victim in those
early days of patient safety, we didn’t really know how to best help them. We
often simply made available to them professional assistance (employee
assistance programs or psychological counselling). Over the years, helping the
“second victim” has evolved considerably and such referral for professional
help is not a good firstline strategy and may even be
counterproductive.
In our December 17,
2013 Patient Safety Tip of the Week “The
Second Victim” we described some of the excellent work done in developing
“second victim” programs by Wu and colleagues at Johns Hopkins and by Susan Scott
and colleagues at the University of Missouri. Scott et al. (Scott
2009) interviewed 31 second victims (10 physicians, 11 nurses, 10 other)
involved in serious events and identified 6 stages that constitute the natural history of second victims. They
found that, regardless of the gender or profession or years of experience of
the healthcare worker, the second victim phenomenon is a life-altering
experience with long-term impact. Both psychological symptoms and physical
symptoms were common in second victims. Intensity varied and was often
influenced by factors such as the relationship the provider had with the
patient or family or the age of the patient being similar to that of a
provider’s family member. External stimuli (eg. same
location, similar name, similar diagnosis) often triggered thoughts about the
incident. But they found that “second victims” typically went through the
following 6 stages:
- Chaos and accident
response
- Intrusive reflections
- Restoring personal
integrity
- Enduring the “inquisition”
- Obtaining emotional first
aid
- Moving on
See our December 17,
2013 Patient Safety Tip of the Week “The
Second Victim” or the original study by Scott and colleagues (Scott
2009) for details about those 6 stages. Their work has since been further expanded. The March/April 2015 issue of Patient Safety &
Quality Healthcare has an article on the “second victim” that every healthcare
organization needs to read. That article (Hirschinger
2015) summarizes lessons learned over 5 years of the University of Missouri program
providing clinician support in such cases. The program they built has 3 tiers.
The first tier is immediate “emotional first aid” from colleagues and/or
supervisors. In the second tier, trained peers monitor the colleagues for
“second victim responses” and provide support in both one-on-one sessions
(“caring moments”) and group debriefings. The third tier is access to
professional services beyond the capabilities of the trained peers. The system
relies heavily on the use of trained peers who have volunteered to participate.
The paper nicely describes what they look for, how they use services, team
design, safety culture development, and lessons learned (both from peers and
insights from the “second victims” themselves). It discusses how real-time
support is used and how to identify when interventions are necessary (because
many “second victims” do not actively seek support).
There have been
multiple other publications related to the “second victim” in the past two
years. Two new “second victim” programs have recently launched in Maryland (Pitts
2015). These actually resulted from the work done by Albert Wu, M.D., who
is generally recognized as coining the term “second victim” (Wu
2000) and was developed by the Maryland Patient Safety Center and Johns
Hopkins’ Armstrong Institute for Patient Safety and Quality. The program has
rolled out at Greater Baltimore Medical Center and will soon be launched at the
University of Maryland Medical Center. Each facility
assembles a team of about two dozen peer responders (physicians, nurses,
administrators and others) who get comprehensive training using case studies
and videos. They brainstorm possible scenarios and act out scenarios. Effective
listening is the most critical skill for team members.
In our December 17,
2013 Patient Safety Tip of the Week “The
Second Victim” we discussed many of the symptoms experienced by healthcare
workers following a serious incident in which they were involved. One recent
study from Belgium reveals the personal and professional tolls taken on second
victims (Van
Gerven 2016). The study looked at responses from
a sample of almost 6000 physicians and nurses at Belgium acute and psychiatric
hospitals. 9% of participants reported having been personally involved in a patient
safety incident in the preceding 6 months. Compared to those who had not been
involved in an incident, those who were involved in an incident (the “second
victims”) were found to be at a greater risk of burnout, more prone to
problematic medication use and to greater work-home interference, and to more
turnover intentions. Moreover, they found that incidents resulting in harm to a
patient predicted problematic medication use, risk of burnout, and work-home
interference. There were some differences between physicians and nurses.
Patient safety incidents were more likely to be related to problematic
medication use in physicians and more excess alcohol consumption in nurses. And
the relationship between actual patient harm and work-home interference and
turnover intentions was stronger in respondents from psychiatric hospitals. The
authors note that the occurrence of these personal and professional adverse
consequences following a patient safety incident might put these physicians and
nurses at risk for future patient safety incidents as well, highlighting the
importance of implementing programs to help “second victims”.
Another recent study compared emotions and coping mechanisms
between the UK and US (Harrison
2015). Though the authors had suspected differences such as the litigation
climate might impact these, they found little evidence of such a difference.
Interestingly, they also found little difference between emotional responses
and severity of the incident. Overall, a third of respondents reported that
either their work performance or personal life suffered at least moderately
following an incident. As expected, negative emotional responses were more
common than positive ones. While many had strained relationships with
colleagues, 56% actually valued their relationships with colleagues more
following the incident. And the vast majority (84%) noted they paid more attention
to safety issues following the incident. As in many other studies, differences
between physicians and nurses were noted. Nurses had more of the following
emotions: upset, worried, distressed, scared, and nervous. Coping strategies
included “approach” strategies (eg. discussing the error with colleagues or superiors) and “reappraisal” and learning from mistakes.
Just over half of the respondents were aware of organizational support services
and 49% expressed willingness to access them. However, many noted feelings of
shame and fears over confidentiality as barriers to using such services.
Importantly, many expressed that support from a trusted existing resource (such
as a peer) was preferable to a formal service.
Perception of the
level of institutional support available after a patient safety event was
also an important issue in another recent study. Joesten
and colleagues surveyed healthcare workers at a large community teaching
hospital (Joesten
2015), using one of several tools available from MITSS (Medically Induced Trauma
Support Services), a non-profit organization whose mission is to support
healing and restore hope to patients, families, and clinicians impacted by
medical errors and adverse medical events. Of a convenience sample of 365
individuals, 73% answered that they had been directly involved in a patient
safety event within the past 3 years. However, over half of those did not
answer any of the items on the survey, leaving 120 evaluable surveys. Most of
the respondents were female nurses, practicing a median 16 years. Symptoms of
the “second victim” phenomenon were present in many respondents. But, notably,
a significant proportion of respondents were unaware of services available to
them (including guidance from a disclosure support team member, personal legal
advice and support, opportunity to take time out from clinical duties, and
access to counseling). Those that were aware of available services generally
found them to be useful. Interestngly, 64% of
respondents agreed they experienced support from their clinical colleagues but
only 38% noted support from managers or chairmen. Also notable was that 60%
disagreed that they could report a patient safety event without fear of
retribution. This study highlights two things. First, it’s not enough to just
have services available. You need to make everyone aware of the program and its
usefulness. Second, it again emphasizes how “culture” trumps everything else.
In a culture where fear of retribution is widespread, it is difficult to
implement even programs designed to help the frontline healthcare worker.
In an editorial, Edrees and
Federico (Edrees
2015) note that although these and other studies have been useful in
further understanding the problem of second victims in healthcare, future
studies should focus on organizational culture and the willingness of second
victims to access support services after an unanticipated adverse event. They
also call for studies that focus on identifying and mitigating institutional
barriers for supporting second victims.
Most studies on the “second victim” have chronicled the
negative symptoms and experiences a healthcare worker suffers after a serious
event. But a recent study (Plews-Ogan
2016) looked at factors associated not just with “coping” after a
medical error but with growing and achieving positive outcomes. The authors
interviewed 61 physicians who had made a serious medical error. The study was
likely biased towards those who had positive outcomes since they were recruited
via advertisement and word of mouth. Nevertheless, the findings offer
significant insight into factors that help such physicians have positive
outcomes. They identified eight themes reflecting what helped physician “wisdom
exemplars” cope positively:
- talking about it
- disclosure and apology
- forgiveness
- a moral context
- dealing with imperfection
- learning/becoming an
expert
- preventing
recurrences/improving teamwork
- helping others/teaching
Talking about it
is a strategy always noted in studies about second victims. However, the
interesting insight from this study was that it was crucial that the person
they talked to did not downplay the
seriousness of the error. They note that there is a “tendency of
well-intentioned colleagues to minimize, dissolve, deny or attempt to solve the
error, which they did not find helpful.” They noted they needed to share both
the medical aspects of the error and the emotional ones. They also found that
in talking others often shared their own mistakes, letting the physician
understand they were not alone.
We’ve discussed disclosure
and apology in multiple columns (see full list below). Physicians who had
positive outcomes were more likely to have disclosed the error to patients or
their families and apologized. This helped patients and families understand the
physician cared. There was even one instance where the disclosure and apology
was met with anger by the patient but the physician went back a second time to
apologize and the patient said “I know you care about me…I forgive you”.
Foregiveness
from the patient/family was often the result of disclosure and apology but some
noted it was also a struggle to forgive themselves without lowering their
standards or “letting themselves off the hook”. Several noted how the moral context (eg.
spirituality or professionalism) helped them to do the right thing, citing how
discussions with mentors or even a medical student helped them do the right
thing.
Dealing with imperfection was a key theme but those with
positive outcomes realized they could be “imperfect
but good” physicians.
The last three themes are related. Those with positive
outcomes often strived to learn about and become
experts about the knowledge or technical deficiencies involved. They also
participated in figuring out what happened and fixing it, preventing similar events, and teaching
others about it.
The study has important implications for organizations. We
need to train physicians to provide peer support in the proper way, serving as
“an ear” that listens and does not try to minimize the seriousness of the
event(s). Also noted was that many of the responding physicians noted they had
never been trained on how to do disclosure and apology so we need to do a
better job of preparing physicians for that. And changing our culture to
recognize we are not perfect needs to start in medical school and extend
throughout our careers.
As we have evolved in patient safety toward full disclosure
and apology when adverse events occur (see our many columns on disclosure and
apology listed below) there has been a lag in preparing clinicians to
participate in such activity. Carolyn Clancy, in an editorial on how we should
approach second victims (Clancy
2012), noted how the evolving practice of disclosure and apology might be a
means of alleviating the emotional trauma of both the first and second victims
of patient safety events. A recent study of how surgeons address adverse
clinical events with their patients and/or patient families is most telling (Elwy 2016).
Elwy and colleagues surveyed surgeons in the Veterans Affairs medical system
about their experiences in disclosing adverse events. Most of the respondents
to the survey used 5 of 8 recommended disclosure items:
- why
the event happened (92%)
- expressed
regret for what happened (87%)
- expressed
concern for the patient’s welfare (95%)
- disclosed
the adverse event within 24 hours (97%)
- discussed
steps taken to treat any subsequent problems (98%)
But use of the other 3 recommended disclosure items was less
frequent:
- apologized
to patients (55%)
- discussed
whether the event was preventable (55%)
- discussed
how recurrences could be prevented (32%)
They found that surgeons who reported they were less likely
to discuss preventability of the adverse event, those who stated the event was
very or extremely serious, or who reported difficult communication experiences
were more negatively affected by disclosure than others. Those surgeons with
more negative attitudes about disclosure at baseline reported more anxiety
about patients’ surgical outcomes or events following disclosure. The study clearly
highlights the need for training for disclosure and apology and development of
skillsets to use for such. Logically, it might be anticipated that development
of those skills might reduce the negative experiences with disclosure and
apology on the part of surgeons and perhaps be a first step in aiding the
“second victims”, too.
In all our years in both clinical medicine and patient
safety we’ve always found that personal stories are much more compelling than
any study. We noted several such personal stories in our December 17, 2013 Patient Safety Tip of the
Week “The
Second Victim”. But we can’t do it any better than the story by Sarah Kliff
in Vox earlier this year (Kliff
2016). She tells the tragic story of Kim Hiatt, an
experienced and compassionate nurse who struggled after a medical error and
ultimately took her own life. This emphasizes the plight of the second victim
and how our systems often fail to identify the needs of the second victim and
provide the right kinds of support to our colleagues and coworkers in their
greatest time of need. We can’t just sit back and wait for them to ask for
help. We need proactive programs in place that anticipate the stages a “second
victim” will go through and be there at the right time for them with the skills
needed to help them cope and not only mitigate the negative effects but also
grow and achieve positive outcomes. It takes a strong organizational commitment
to develop programs like those in Maryland and Missouri but some day each one
of us could be a “second victim” and need such a program.
Some of our prior
columns on Disclosure & Apology:
July 24, 2007 “Serious
Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple
Patients”
June 22, 2010 “Disclosure
and Apology: How to Do It”
September 2010 “Followup
to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI:
Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error
Disclosure by Surgeons”
June 2012 “Oregon
Adverse Event Disclosure Guide”
December 17, 2013 “The
Second Victim”
July 14, 2015 “NPSF’s
RCA2 Guidelines”
June 2016 “Disclosure
and Apology: The CANDOR Toolkit”
Other very valuable
resources on disclosure and apology:
- IHI’s “Respectful
Management of Serious Clinical Adverse Events” (Conway
2010)
- The Canadian Disclosure
Guidelines (Canadian
Patient Safety Institute 2008)
- The Harvard Disclosure
Guidelines (Massachusetts
Coalition for the Prevention of Medical Errors 2006)
- The ACPE Toolkit (American College
of Physician Executives)
- Oregon Patient Safety
Commission Oregon
Adverse Event Disclosure Guide.
References:
Wu AW. Medical error: the second victim. The doctor
who makes the mistake needs help too.
BMJ 2000; 320: 726–727
Scott SD, Hirschinger LE, Cox KR,
et al. The natural history of recovery for the healthcare provider “second
victim” after adverse patient events. Qual Saf Health Care 2009; 18(5): 325-330
http://qualitysafety.bmj.com/content/18/5/325.full?sid=495da4c7-557e-45ec-a01e-54538e9ebc1f
Hirschinger LE, Scott SD,
Hahn-Cover K. Clinician Support: Five Years of Lessons Learned. Patient Safety & Quality Healthcare 2015;
March/April 2015. Published 03 April 2015
http://psqh.com/march-april-2015/clinician-support-five-years-of-lessons-learned
Pitts J. Program helps caregivers under stress after errors.
The Baltimore Sun 2015; June 21, 2015
Van Gerven E, Vander Elst T, Vandenbroeck S, et al.
Increased risk of burnout for physicians and nurses involved in a patient
safety incident. Med Care 2016; [Epub ahead of print]
May 20, 2016
Harrison R, Lawton R, Perlo J, et
al. Emotion and Coping in the Aftermath of Medical Error: A Cross-Country
Exploration. Journal of Patient Safety 2015; 11(1): 28-35
Joesten L, Cipparrone
N, Okuno-Jones S, DuBose
ER. Assessing the Perceived Level of Institutional Support for the Second
Victim after a Patient Safety Event. Journal of Patient Safety 2015; 11(2): 73-78
MITSS (Medically Induced Trauma Support Services)
http://www.mitsstools.org/index.html
Edrees H, Federico F. Supporting
clinicians after medical error. (Editorial). BMJ 2015; 350: h1982 (Published 15
April 2015)
http://www.bmj.com/content/350/bmj.h1982
Plews-Ogan M, May N, Owens J, et
al. Wisdom in Medicine: What Helps Physicians After a
Medical Error? Acad Med 2016; 91(2): 233-241
Clancy CM. Alleviating “Second Victim” Syndrome: How We
Should Handle Patient Harm. Journal of Nursing Care Quality 2012; 27(1): 1-5,
January/March 2012
Elwy R, Itani KMF, Bokhour BG, et al. Surgeons’ Disclosures of Clinical
Adverse Events. JAMA Surg 2016; Published online July 20, 2016
http://archsurg.jamanetwork.com/article.aspx?articleid=2534133
Kliff S. Fatal mistakes. Doctors
and nurses make thousands of deadly errors every year. They are reprimanded. Do
they also deserve support? Vox 2016; March 15, 2016
http://www.vox.com/2016/3/15/11157552/medical-errors-stories-mistakes
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