This article appears in the February 2013 edition of Patient Safety Monitor.
Mistakes happen. Many times when mistakes happen in hospitals, the hospital's system a nd process design has at least in part failed a frontline provider. How much of a human error is truly the fault of the hospital could probably be under debate well after the incident. However, no matter what is eventually determined, there is usually at least one person who works for the hospital who will suffer being the second victim.
The first victim, of course, is the patient and family affected by a patient care mistake. Sometimes these mistakes are minor and sometimes they are fatal. Much has been researched about patient safety, and in recent years, attention has also turned toward these second victims-providers involved in the adverse event, who are also the hospital's responsibility. Evidence suggests these second victims, if not given the correct support, can contribute to further patient safety problems; and, of course, each person in a work system affects culture.
What happens after an event is critical to the future of a hospital's culture of safety. Not only could an unsupported second victim suffering intense emotional distress be more likely to make mistakes, but how this second victim is treated will be noted by other providers and staff who contribute to patient care.
If this person is penalized, punished, or simply ignored, nurses, housekeepers, physicians, etc., might think twice before reporting their own or someone else's next mistake. They might lose faith in leadership and lose desire to participate in quality initiatives. The idea of a culture of safety is to work together to avoid mistakes, but it's important that quality directors, nurse managers, and leadership understand that a strong culture means addressing an event head-on.
More than a decade of research on second victims
A new literature review has identified some interesting evidence on second victims and the effect second victims have on hospital culture.
Although evidence found that being part of an adverse event can make a provider more prone to future errors, a hospital can avert that possibility by providing emotional support.
"Let us not forget that some second victims react in a very positive way after being involved in an accident: They ask more questions, follow additional training, are more precise, … so not all second victims are at risk for additional failures. Therefore I think that emotional support is necessary immediately after the event," says Kris Vanhaecht, MD, RN, MSc, PhD, leader of Health Services Research Group, School of Public Health, KU Leuven, University of Leuven, Belgium. Vanhaecht coauthored the study "Supporting involved health care professionals (second victims) following an adverse health event: A literature review" published in the International Journal of Nursing Studies in July 2012. A total of 21 research articles and 10 non-research articles were cited in the literature review, which found that a hospital should have a plan in place for addressing the needs of second victims and should identify the organization as a whole as a third victim.
How a healthcare organization reacts to a second victim can be crucial for its future culture of safety.
One study in this literature review stated: "When healthcare institutions do not support their people, they will lose all the trust and respect and in the long term it will harm the culture of the organization."
"It is clear that after an adverse event [AE] there can be three types of victims. The first victim, the most important one, is the patient and his or her family. The second victim is the involved healthcare professional and team members. The third victim is the involved organization and the involved managers," says Vanhaecht, who taught quality in healthcare within the School of Medicine when an experience triggered his interest. During exams, students analyze and discuss a case study on an AE.
"One evening, two medical doctors each discussed an AE in which they were personally involved. Both of their patients died because of what we call a system failure, but in both cases they were the human element. One of the MDs coped in a positive way after the AE: He learned from it, he talked about it with his junior doctors and nurses, all despite the lack of support after the event."
The second MD had a more negative reaction after the event: He could not sleep for weeks, was afraid to talk about it, wanted to change jobs, was talking about a personal failure, and had very low self-esteem," says Vanhaecht. "He even started to cry during the exam and explained to me that it was the first time he talked about the event in such detail. He even apologized for his 'childish behavior.'
Vanhaecht was intrigued by the stories he heard and sought out more information. He contacted James Conway, MD, then senior vice president at the IHI who also authored the literature review. Conway put him in touch with Albert Wu, MD, MPH, a Johns Hopkins professor who introduced the term "second victim" in a British Medical Journal article back in 2000, and Sue Scott, a researcher on second victims at the University of Missouri, both coauthors of the review.
Vanhaecht also spoke with Medically Induced Trauma Support Systems, which has in place systematic support design for second victims. In December 2012, Vanhaecht also presented his findings at the IHI's annual forum.
"Although I had been working on quality in healthcare for years, a new world opened up for me after talking with these experts. It was clear that this phenomenon was not something new, but it was very clear that there was a lack of knowledge and evidence about second victims," he says.
Understanding the second victim
Second victims are defined by Scott as healthcare providers involved in an unanticipated adverse patient event, medical error, and/or patient-related injury who become victimized in the sense that the provider is traumatized by the event. Some suffer posttraumatic stress disorder.
Research is still revealing exactly how to help these providers. Many hospitals know that involving a second victim in a root cause analysis and following process redesign can help him or her find solace; meanwhile, the hospital has a goal to proactively work toward-avoiding the same event in the future. However, the study notes that while involvement can be quite helpful, without sufficient emotional support for the second victim, the process can be "associated with heightened emotional stress."
Not surprisingly, if victims are suffering from posttraumatic stress, as evidence suggests, then much of the quality efforts could force the victim to relive the incident. The paper concludes that without proper support during this time, involvement in the correction process may backfire and further victimize this group.
Viewing an event as traumatizing and treating the person involved as suffering from trauma can help hospital leaders understand what the second victim is going through and how to help. For example, just like many other types of victims, these victims benefit from hearing and connecting with others who have been involved in a similar adverse event.
Common feelings of second victims include guilt, shame, fear, and loss of confidence. According to KU Leuven Research's website on second victims, many experience:
- Post-traumatic stress
- General stress symptoms
- Anger
- Insomnia
- Nervousness
- A deterioration in family life
- Depression
"The reactions of second victims have two sides: professional and personal. The professional impact is a change in behavior within the team, feeling unsafe among team members, behaving differently toward other patients and family members, burnout, and very importantly, doubt about their knowledge and skills, and this increases the risk of additional failures," says Vanhaecht.
"In their personal lives we see symptoms like insomnia, general stress symptoms, anger, fear, nervousness, depression, substance use [alcohol and medication], and there are cases of suicides. The most known case is that of Kimberly Hiatt, a nurse from Seattle who committed suicide after accidentally giving a baby a fatal overdose." Hiatt's mistake came after a 24-year accident-free career. She was fired after the incident.
Second victims who openly discuss an adverse event with colleagues often find doing so stress relieving; however, rarely are they so open for fear of tarnishing their professional reputation. It can be therapeutic for second victims to have a safe space to discuss the event, in which what they say remains confidential.
However, and perhaps not surprisingly, discussing the event with the patient is a different story. It is seen as a source of emotional stress for physicians.
Managers should discuss the event with the second victim as well; however, talking in and of itself is not enough. Managers need to recognize what types of communication would be most beneficial to the discussion. Sharing an event they experienced themselves can be helpful, and conveying to the second victim that they are trusted and supported by the manager and organization is helpful as well. Key phrases identified by the literature review as being helpful include:
"This has been difficult. Are you okay?"
"I believe in you."
"I cannot imagine what that might have been like for you. Can we talk about it?"
"You are a good nurse working in a very complex environment."
Being available to the second victim and knowing his or her whole story surrounding the event is crucial. A positive relationship with the patient or family involved can also be beneficial.
The organizational culture and behavior will affect how well the second victim overcomes his or her trauma. Open and confidential discussion with peers is crucial, as is the opportunity to have this conversation immediately after an event, before a provider leaves the clinical setting.
"Because of the impact of the AE on both the professional and personal life of these second victims, there can be additional victims who we must not forget," says Vanhaecht.
"These are, on the one hand, new patients who are in danger because of doubt in the second victims' skills and knowledge, creating a higher risk of other mistakes. Next to that, we must not forget the impact of the AE on the personal life of the second victim. The second victim's family, friends, and colleagues are also indirectly victimized and can be confronted with these negative effects."
Barriers to support
To begin with, having a culture of safety and transparency is crucial to ensuring a healthy environment in which your second victim can cope.
One study in the literature review found that physicians involved in an AE rarely saw a counselor or psychologist, and indicated that the most difficult part of the process was forgiving themselves.
"Also noted in the literature review as a barrier to overcoming second victim phenomena is the stigma of healthcare providers seeking mental health counseling," says Vanhaecht.
Vanhaecht recently spoke with a group of surgeons who thought it was possible that all surgeons might experience being a second victim at some point in their career. The issue, of course, is also generational, as physicians and healthcare providers with decades-long careers vividly remember a culture that swept errors under the rug.
Most AEs are a result of system failures, and most of the time more than one professional is involved in such an event. While healthcare is working toward a team model, there is frequently one person who made the final human contribution to an event, and he or she can become victimized despite several people taking part in the patient's care.
However, Vanhaecht says the research shows that the entire care team can be immediately victimized, particularly in settings like the operating room. He suggests a rapid response team style for support in such events.
Creating your support design
Immediate support was found necessary by 60% of second victims in one study; follow-up support that involved staff specifically trained in second victim trauma and follow-up was necessary for 30%; and 10% needed support that included outside professional counseling.
Particularly for nursing, immediate support by colleagues is crucial to helping the second victim. Department managers must be aware of the organization system for handling errors, especially regarding second victims.
For physicians, morbidity and mortality meetings are a key step in identifying errors. The literature shows no consensus for how to effectively support second victims or how best to design a support program. Some hospitals have begun to integrate emotional support in their root cause analysis, but some experts believe that this should be handled as a separate function.
Medical and nursing students can also be second victims, and therefore must be included in organizational planning. The literature review mentions a recommendation that students have frequent meetings to discuss mistakes, even ones with positive outcomes.
Vanhaecht says that it's quite possible for many hospitals to lack protocol for second victims, and notes that many might not have a protocol that meets recommendations provided by the IHI (Respectful Management of Serious Clinical Adverse Events).
This article appears in the February 2013 edition of Patient Safety Monitor.