Last week we were following the NTSB investigation of the tragic Asiana plane crash in San Francisco this past July. Our regular readers know we often use aviation analogies to help us understand root causes that underlie many of the adverse events we see in healthcare. The current NTSB investigation, of course, is loaded with examples that apply equally to aviation and healthcare, including training issues, learning curves, failure to heed alarms, failure to buck the authority gradient, cultural barriers, automation surprises, safety systems temporarily unavailable while under repair, and many more. At some point we’ll probably do a full review of the NTSB investigation with lessons learned that can be applied to healthcare.
But what caught our attention in this case were the “second victims”. The primary victims in this crash, of course, were the passengers and crew members who were injured or killed. “Second victims” are personnel involved in the errors that lead to adverse outcomes, be they in aviation or in healthcare. In the NTSB case they might be the pilot, copilot, first officer, etc. In healthcare they are most often physicians and nurses and pharmacists. Albert Wu, M.D. is generally recognized as coining the term “second victim” (Wu 2000).
In the Asiana crash we couldn’t help but wonder how the lives of the pilot, copilot, first officer, driver of the rescue vehicle that ran over a victim, and others have been impacted and what support was rendered to them after this terrible accident. In healthcare we still do a suboptimal job of attending to the needs of second victims.
Our July 24, 2007 Patient Safety Tip of the Week “Serious Incident Response Checklist” linked to a checklist we developed back in the early 1990’s to ensure attention to critical things an organization needs to do after a serious event (). The last item on the checklist, support for caregivers involved, is very important and often overlooked. Caregivers undergo a variety of deep emotions when one of their patients is harmed, particularly when they feel they may have contributed in some way to that adverse outcome. So each organization must have some mechanism for providing needed support and assistance to any physicians, nurses, pharmacists, etc. that may have been directly or indirectly involved in the incident or had been actively involved in the care of the patient.
One of the most important contributions to our understanding of “second victims” came from researchers at the University of Missouri (Scott 2009). Scott and colleagues 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:
The first stage is what occurs immediately after the adverse event and consists of trying to realize exactly what happened, often while continuing to care for an unstable patient. The second stage was characterized by “a period of haunted re-enactments”. Feelings of personal inadequacy and periods of self-isolation were common during this period and caregivers often repeatedly asked themselves “what if?”.
The third stage involved seeking support from a trusted individual, often a colleague or supervisor or personal friend or family member. But many could not identify such a trusted individual. During this period they endured doubts about their professional career and worry about whether others would ever trust them again. Particularly critical here was lack of support. Particularly when departmental colleagues or those in supervisory roles were not supportive those feelings of doubt increased. The rumor mill can be especially dangerous. But just as much harm comes from others avoiding the second victim or avoiding talking about the events. (Note that this stage typically occurs before the root cause analysis is done and before all the facts and contributing factors may be known. It is one reason we always recommend the RCA begin as soon as possible after a serious adverse event.)
The fourth stage, enduring the “inquisition” is where the second victim realizes that the organizational response to the events may have repercussions for them. This is where the second victim wonders “will I lose my job?”, “will I lose my license?”, “will I be sued?”, etc.
The fifth stage is seeking emotional support from others (loved ones, coworkers, colleagues, supervisors, or professional support services). But often second victims even had questions about what they could discuss because of legal and regulatory (eg. HIPAA) considerations.
The last stage really is one of 3 paths the second victim might follow. Some “dropped out”, meaning they changed their professional role, moved to a different practice setting, or even left their profession. Others “survived”, meaning they continued to practice at expected levels but continued to be plagued by the event. Yet some “thrived”. Those were the ones who had something positive come out of the experience.
The culture of an organization is extremely important in determining how well second victims are supported. If an organization truly takes a learning approach in their RCA’s and focuses on system factors and avoids the “blame and train” approach, many of the stages of the second victim natural history may be ameliorated. But don’t fail to understand that the culture of an individual department may differ from that of the overall organization. That local departmental culture may trump all attempts by the organization to foster Just Culture.
The root cause analysis (RCA) is also critically important. We’ve already noted that the promptness of the RCA is important in getting out the facts and quelling the “rumor mill”. The goal of the RCA is to identify factors that contributed to the event with the intent of changing them so that future similar events do not occur. It is extremely important that during the RCA we attempt to put ourselves in the position of the players as events unfolded. It’s all too easy for us to have hindsight bias and say or think things like “why didn’t they see that obvious…?”. In almost every RCA we participate in there will be several others who breathe a sigh of relief that they were not put in the same position that the second victims were put in. That recognition often leads to helping provide the sort of organizational and colleague support necessary for helping get a second victim into a desirable “path”.
That, of course, raises the question about who should be involved in the RCA’s. Your RCA should not be about “who?” but rather about “why?”. The questions you should be asking are:
Our feeling is that the people who are involved, no matter what their hierarchical status, can tell you not only where and what the problems are, but also how to fix them. So we feel that those involved in the event should be at the RCA table. But there are pros and cons. On the pro side, you need to know what they were thinking as events evolved. On the con side, you need to avoid empathy for staff involved precluding objective evaluation of facts. Unfortunately, even in this day and age of transparency and adopting the concept of disclosure and apology, we still see some individuals who are unwilling to participate in the RCA. This often comes from the usually misguided perception that anything they might say could be legally “discovered”. We usually point out to such individuals that things they might say during the RCA are much more likely to be mitigating and helpful to them. There are also rare circumstances where an involved party might not be invited to “sit at the table”. Those are cases where there is a clear “hierarchical” problem in the organization and it is likely that other participants or witnesses may be intimidated enough to prevent them from speaking out honestly and completely.
But most important is that the second victim receive feedback in a prompt fashion after the RCA and investigation have taken place. A recent study (Ullstrom 2013) found that many second victims needed to understand and learn from the event. But many of the second victims reported lack of followup after conclusion of the investigation.
Providing support for the second victim has to be better thought out. We’ve evolved over time. We have to admit that when we first added that step to ourin the early 1990’s we usually just made sure that the second victim was hooked up with the organization’s EAP (employee assistance program) program. That’s not what we are looking for today! While some second victims may eventually need support from outside or professional counseling, it is the support from colleagues and coworkers that is much more likely to have a positive impact. Virtually all studies done on second victims indicate the need for support from colleagues and supervisors.
Physicians in training may be particularly vulnerable (Wu 1991, Wu 2012) and whether they get support from colleagues and/or mentors or supervisors is critical. Wu and Steckelberg (Wu 2012) note that some organizations, such as Johns Hopkins Hospital and the University of Missouri and the University of Illinois at Chicago, have formal programs for second victims.
There are some tools and resources readily available that may help your organization deal more effectively with “second victims”. MITSS (Medically Induced Trauma Support Services) is 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. Several of the authors noted above are advisors to this organization which has developed very useful toolkits to help both patients/families and clinicians/second victims cope in the aftermath of significant adverse events. MITSS makes available an organizational assessment tool for clinician support, a sample comprehensive workplan for organizations, and a clinician support toolkit. In addition, they have videos from actual second victims that describe how second victims have been able to turn their bad experiences into something positive.
Two literature reviews in recent years (Lewis 2013, Sirriyeh 2010) have noted that, although negative emotional and psychological responses after medical errors are widespread, positive outcomes may occur as well. A lot depends upon the culture of the workplace and the organizational response to the incident. Improved professional relationships following discussion of an error have been reported by physicians. Improved teamwork due to increased assertiveness following such incidents has also been reported.
One thing we have felt has been very beneficial for second victims is the trend to disclosure and apology. You’ll note that in our , which we developed in the early 1990’s, notification of the patient and/or family was deemed essential. We’ve subsequently written numerous columns on disclosure and apology (see the list at the end of today’s column). From personal discussions with many second victims we have found that the net effect on them is that disclosure and apology provides them with a great deal of relief. A study in nurses (Crigger 2007) also emphasized the importance of disclosure and apology in reaching a positive self-reconciliation following mistakes. Our multiple columns on disclosure and apology demonstrate that such is best for all involved, the patients and families, the professionals involved, and the organization. It is one of the key elements in helping all move to closure and something positive coming out of unfortunate events.
Actually, we would really define at least two subtypes of second victims. One type is the person most directly involved with the error that may have been the proximate cause of the adverse event. The other type is the person who knew that something was not right but did not speak up forcefully enough to change the course of events. Both likely suffer from the many negative reactions experienced by all second victims but each may have some unique reactions. Understanding these may be helpful in designing support systems for each of these second victims. The latter type of second victim is less likely to question their clinical abilities or fear licensure actions or loss of employment but still may feel intense guilt. We’ve found that the policy of disclosure and apology has had a positive impact on this type of second victim. In the old era they would live with constant feelings of guilt that no one ever revealed what had happened. Another recent review of the literature on nurses’ experience of medical errors (Lewis 2013) also noted that most nurses feel that patients and family members have a right to be told about medical errors and that failure to disclose increased feelings of distress in the nurses. But many nurses were unclear about their roles in such disclosure.
Another manner of helping the second victims to “move on” is to actually involve them in describing to others what happened to their lives after their adverse event. You have heard us use the phrase “stories, not statistics” many times (see our December 2009 What’s New in the Patient Safety World column “Stories, Not Statistics”). Stories are powerful ways to get the attention of healthcare providers and get them to say “Wow. I bet that could happen here”. Many of those stories are told by the families of primary victims of incidents. However, even more powerful are those stories told by healthcare workers who were the second victims. When you hear their stories you leave thinking “that could easily have been me”. While reliving the events and telling there stories can be very stressful for second victims, it also provides something positive in that they at least know their stories may help prevent future similar primary and second victims.
For example, we’ve seen signs of disinterest in audiences hearing about surgical fires. You can almost hear them thinking “We’ve never had a fire in our OR” or “That’ll never happen there”. But let a surgeon or anesthesiologist or nurse tell them how their lives were impacted after such a fire and that will get their attention! It also brings considerable comfort to the person telling the story knowing that they may be helping to prevent harm to someone else.
In our January 31, 2012 Patient Safety Tip of the Week “Medication Safety in the OR” we noted how anesthesiologists have used the technique of “stories, not statistics” to help prevent errors. We noted a medication safety video from the Anesthesia Patient Safety Foundation (APSF 2012) that includes some clips you may have previously seen in ISMP videos highlighting testimonials from some providers at the “sharp end” of unfortunate medication incidents in the OR. That video and their Spring 2010 Newsletter (APSF 2010) provide real-life examples of errors that led to deaths or other serious outcomes. Most of you are also familiar with the “Beyond Blame” video (available through ISMP online store in the US) and we mentioned above the videos available through MITSS (Medically Induced Trauma Support Services). Using such “stories” or real-life examples, told from the point of “the second victim” (the provider involved), is a very useful way to get buy-in from all parties to address potentially serious problems.
Clearly the “second victim” phenomenon is a very real and serious problem. Many very good people have had their lives devastated by adverse events in which they were involved. Some never fully recover, some leave their profession, yet others recover and make something positive come out of the experience. We all need to do a better job of helping those second victims move toward the latter outcome. That means developing a learning culture for the organization, avoiding a “blame and shame” culture, providing prompt feedback to involved parties when there is an investigation or RCA, providing peer level support for involved parties, and endorsing the disclosure and apology approach to dealing with medical errors, and giving second victims a chance to “tell their story” to others in a constructive manner. Having a formal process for identifying and helping second victims is a must for all healthcare organizations. We also need to look at all levels of our organizations. Sirriyeh et al. (Sirriyeh 2010) note that most of the literature on dealing with medical errors is based on events in hospital settings and very little is known about responses to errors in ambulatory settings. Clearly, we have a big opportunity to learn more about dealing with the “second victim”.
Update: See our August 9, 2016 Patient Safety Tip of the Week “More on the Second Victim”.
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “ ”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
Other very valuable resources on disclosure and apology:
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
Ullström S, Sachs MA, Hansson J, et al. Suffering in silence: a qualitative study of second victims of adverse events. BMJ Qual Saf 2013; Online First 15 November 2013 doi:10.1136/bmjqs-2013-002035
Wu AW, Folkman S, McPhee SJ, et al. Do house officers learn from their mistakes? JAMA 1991; 265: 2089–94
Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf 2012; 21(4): 267-270
MITSS (Medically Induced Trauma Support Services)
Lewis EJ, Baernholdt M, Hamric AB. Nurses' Experience of Medical Errors: An Integrative Literature Review. Journal of Nursing Care Quality 2013; 28(2): 153-161, April/June 2013
Sirriyeh R, Lawton R, Gardner P, Armitage G. Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being. Qual Saf Health Care 2010; 19(6): e43 Published Online First: 31 May 2010
Crigger NJ, Meek VL. Toward a Theory of Self-Reconciliation Following Mistakes in Nursing Practice. Journal of Nursing Scholarship 2007; 39(2): 177–183
APSF (Anesthesia Patient Safety Foundation). Medication Safety In The Operating Room: Time For A New Paradigm (video). 2012
APSF (Anesthesia Patient Safety Foundation). APSF Newsletter. Spring 2010
ISMP. “Beyond Blame” video (available through ISMP online store in the US)
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