NEWSPAPER/MAGAZINE ARTICLE
Supporting second victims.
Quick Safety. January 22, 2018;(39):1-3.
Involvement in patient harm can result in serious psychological consequences for health care workers. This newsletter article describes problems second victims may experience and outlines how organizations can support providers after an error.
MEETING/CONFERENCE > MISSOURI MEETING/CONFERENCE
Second Victim Experience.
Missouri Center for Patient Safety. November 5, 2018; Saint Luke’s North Hospital, Kansas City, MO.
Second victims are clinicians who experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. This workshop will explore strategies that addresses individual stages of recovery and trains peers to participate in that process. Sue Scott will lead the session.
JOURNAL ARTICLE > REVIEW
The second victim: a review.
Coughlan B, Powell D, Higgins MF. Eur J Obstet Gynecol Reprod Biol. 2017;213:11-16.
Maternity care is a high-risk environment. This review discusses second victims in regard to maternity care. The authors highlight the importance of safety culture, disclosure, and peer support as mechanisms to address the needs of staff after adverse events.
JOURNAL ARTICLE > COMMENTARY
Medical error: the second victim.
McCay L, Wu AW. Br J Hosp Med. 2012;73:C146-C148.
Exploring how medical errors affect second victims, this commentary recommends strategies to help them cope with such experiences.
JOURNAL ARTICLE > COMMENTARY
Medical error: the second victim.
- CLASSIC
Wu AW. BMJ. 2000;320:726-727.
This editorial coined the term "second victim" to describe clinicians who commit errors, acknowledging the significant emotional impact that errors can have on the clinicians involved. Subsequent research has shown that involvement in an error adversely affects providers' emotional health and job satisfaction, and increases risk of burnout. Inspired by these findings, organizations have now developed innovative approaches for supporting second victims, primarily through encouraging debriefing and open discussion of errors. An AHRQ WebM&M commentary discusses the effect of committing a wrong-site procedure error on a resident physician.
BOOK/REPORT
Second Victim: Error, Guilt, Trauma, and Resilience.
Dekker S. Boca Raton, FL: CRC Press; 2013. ISBN: 9781466583412.
This book covers how to investigate patient safety incidents while simultaneously providing support for second victims.
JOURNAL ARTICLE > COMMENTARY
Don't abandon the "second victims" of medical errors.
Smetzer J. Nursing. 2012;42:54-58.
This commentary emphasizes the importance of developing a crisis management plan to support clinicians involved in medical error.
JOURNAL ARTICLE > COMMENTARY
Alleviating "second victim" syndrome: how we should handle patient harm.
Clancy CM. J Nurs Care Qual. 2012;27:1-5.
This commentary discusses second victims and describes how blame-free reporting and disclosure can minimize harm.
NEWSPAPER/MAGAZINE ARTICLE
Too many abandon the "second victims" of medical errors.
ISMP Medication Safety Alert! Acute Care Edition. July 14, 2011;16:1-3.
This piece discusses second victims and describes how five factors can help clinicians involved in adverse events.
NEWSPAPER/MAGAZINE ARTICLE
The 'second victims' of medication errors begin to gain support.
Blum K. Pharm Pract News. November 2011.
Exploring the impact of medication errors on clinicians, this article discusses efforts to support second victims affected by medical error.
NEWSPAPER/MAGAZINE ARTICLE
"Second victim" casualties and how physician leaders can help.
MacLeod L. Physician Exec. Jan-Feb 2014;40:8-12.
Second victims are clinicians who experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. This magazine article discusses the need for hospitals to provide care for these clinicians and spotlights the role of physician leaders in promoting and facilitating support programs.
JOURNAL ARTICLE > STUDY
Implementation of a "second victim" program in a pediatric hospital.
Krzan KD, Merandi J, Morvay S, Mirtallo J. Am J Health Syst Pharm. 2015;72:563-567.
The term "second victims" was coined to describe clinicians who commit errors, acknowledging the significant emotional impact that errors can have on the clinicians involved. A structured program to provide immediate support to clinicians affected by medical errors was well received by the pharmacy staff at a pediatric hospital.
JOURNAL ARTICLE > COMMENTARY
TRUST: the 5 rights of the second victim.
Denham CR. J Patient Saf. 2007;3:107-119.
The author discusses the psychological impact of medical error on clinicians and shares interviews with several patient safety experts on this topic. He proposes a list of five rights to which caregivers are entitled following an unintentional error.
JOURNAL ARTICLE > STUDY
Health care workers as second victims of medical errors.
Edrees HH, Paine LA, Feroli ER, Wu AW. Pol Arch Med Wewn. 2011;121:101-108.
Medical errors can have a devastating impact on patients but also place providers—called the second victims—at risk for emotional distress, decreased job satisfaction, and burnout. This study explores the second victim phenomenon, describes current approaches for addressing the emotional impact, and shares survey findings from participants who attended a session on the topic. Respondents expressed the need for informal emotional support and peer support as key coping strategies. The authors offer suggested things to say (and not to say) in providing such support, and emphasize the importance of necessary structures for second victims while building a culture of safety within hospitals. A past AHRQ WebM&M commentary discusses the impact of committing a medical error.
JOURNAL ARTICLE > STUDY
The second victim experience and support tool: validation of an organizational resource for assessing second victim effects and the quality of support resources.
Burlison JD, Scott SD, Browne EK, Thompson SG, Hoffman JM. J Patient Saf. 2017;13:93-102.
The second phenomenon—the damaging psychological impacts of errors on the clinicians who are involved—has been well documented in the literature. This study presents the development and validation of a survey tool to examine clinicians' experiences with errors and evaluate the effectiveness of approaches to aid second victims.
PATIENT SAFETY PRIMERS
Second Victims: Support for Clinicians Involved in Errors and Adverse Events
The first priority following a medical error or adverse event is to attend to the patient and family. However clinicians can also be deeply affected by errors and adverse events and may need structured follow-up to ensure adaptive coping and organization learning.
JOURNAL ARTICLE > STUDY
Suffering in silence: a qualitative study of second victims of adverse events.
Ullström S, Sachs MA, Hansson J, Øvretveit J, Brommels M. BMJ Qual Saf. 2014;23:325-331.
Clinicians who are involved in a medical error experience considerable emotional distress, shame, and self-doubt, and the term "second" reflects these effects. This qualitative study provides vivid examples of the second victimphenomenon in 21 health care professionals (primarily doctors and nurses) who were involved in errors at a Swedish hospital. Interviews with the affected clinicians revealed that the immediate emotional effects were compounded by a lack of institutional support in the weeks to months after the incident. In response to these issues, some hospitals have instituted structured approaches, such as a second victim rapid response team, to provide a non-judgmental sounding board and debriefing opportunity for affected providers after serious medical errors. Dr. Albert Wu, who coined the term second victim and has extensively researched this phenomenon, was interviewed by AHRQ WebM&M in 2011.
JOURNAL ARTICLE > STUDY
Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses.
Quillivan RR, Burlison JD, Browne EK, Scott SD, Hoffman JM. Jt Comm J Qual Patient Saf. 2016;42:377-386.
The second phenomenon describes the distress health care providers can experience after adverse events. This survey of 358 nurses at a single pediatric hospital found that those working in a stronger safety culture were less likely to report distress after involvement in a patient safety event. The authors suggest that bolstering safety culture can help prevent negative effects of second experiences.
JOURNAL ARTICLE > STUDY
Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study.
Edrees H, Connors C, Paine L, Norvell M, Taylor H, Wu AW. BMJ Open. 2016;6:e011708.
Health care workers who experience distress following adverse events are considered second victims. This study described the implementation of a peer support program for second victims. The program initially received few calls for assistance, and most adverse events for which health care workers—predominantly nurses—requested support were not related to medical errors.
JOURNAL ARTICLE > COMMENTARY
Medical error, incident investigation and the second victim: doing better but feeling worse?
Wu AW, Steckelberg RC. BMJ Qual Saf. 2012;21:267-270.
This commentary discusses the impact of adverse events on physicians-in-training and provides tactics to improve support for clinicians affected by medical error.
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