Supporting clinicians after medical errorBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1982 (Published 15 April 2015) Cite this as: BMJ 2015;350:h1982
- 1 Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
- 2Institute for Healthcare Improvement, Cambridge, MA, USA
- Correspondence to: H Edrees
Clinicians who are unable to cope with their emotions after a medical error or adverse event are suffering in silence. These healthcare providers are often told to take care of the next patient without an opportunity to discuss the details of the event or share how this has affected them personally and professionally. While patients and families are the first victims of such events, we refer to the healthcare providers who are involved as the second victims.1
Second victims may feel guilt, fear, anxiety, or anger and experience social withdrawal, disturbing and troubling memories, depression, and insomnia.1 They tend to doubt their clinical skills, feel as though they have failed the patient, and worry about what their colleagues think. They are embarrassed to request emotional support and feel that the organisation has abandoned them. Often, these symptoms are experienced by not only one healthcare provider but a few members of the healthcare team who have either taken care of the patient or were affected by the error because of their role in the organisation or their physical proximity to the event. This can affect the provider-patient relationship, and if not managed properly, organisations can face clinical and financial challenges.
Over time, second victims may develop signs and symptoms related to post-traumatic stress disorder (PTSD). As a result, these healthcare providers have difficulty forgiving themselves2 and some may even commit suicide.3
Recent international headlines highlighted the emergence of suicides related to second victim experiences. These range from direct sentinel events, such as that of Kimberly Hiatt the nurse who committed suicide after a medical error in the US, to more distal errors of disclosure, as in the case of Jacintha Saldanha, the nurse who received a radio prank call asking about the health of the Duchess of Cambridge in the UK.
Addressing the problem of second victims can be a sensitive topic given the stigma attached to being involved in a medical error. Over the past decade, system changes in healthcare have focused on disclosure, reporting, and patient safety culture.4 However, little attention has been paid to creating systems that help second victims after an unexpected adverse event.
There continues to be limited research in this field. In fact, few studies have examined the prevalence of second victims, with reported rates of 10.4% ,5 30% ,6 and 43.3% .7 Several academic and healthcare institutions in Switzerland, Belgium, Sweden, Italy, the United Kingdom, and the United States have conducted studies into the concept of second victims. Many of these studies focused on dealing with the signs and symptoms of second victims after adverse events.1 6 Other studies introduced frameworks, models, and roadmaps for how to meet second victims’ needs.8 9 Although these studies have been useful in further understanding the problem of second victims in healthcare, future studies should focus on organisational culture and the willingness of second victims to access support services after an unanticipated adverse event. Additional studies should also focus on identifying and mitigating institutional barriers for supporting second victims.
When errors happen, second victims may not know who to turn to for guidance. In some instances, informal support offered by colleagues may be harmful. Insensitive comments addressed to the second victim or others about the event can negatively affect those involved. Avoiding contact or conversation with the second victim can also cause harm.
To meet these challenges, several institutions have developed formal organisational support programmes that allow healthcare workers to cope with their emotional distress by seeking timely support in a confidential, non-judgmental environment. For instance, the Medically Induced Trauma Support Services (MITSS) has developed a toolkit of resources to help organisations establish second victim programmes.10 Hospitals and healthcare systems in the United States, such as the University of Missouri, Brigham and Women’s Hospital, Boston Children’s Hospital, Kaiser Permanente, and Johns Hopkins Hospital, have developed organisational support programmes for staff. Each of these second victim support programmes has been incorporated into or was aligned with the organisation’s response to adverse events. Not only have these institutions embraced the concept of second victims, but they have also dedicated resources and time to establish safe delivery systems that help the healthcare provider.
Despite these encouraging developments, a gap remains in addressing the needs of second victims in healthcare. Encouraging the affected healthcare provider to discuss the event and recommend system changes to mitigate future errors from happening is key. Rebuilding second victims’ confidence by holding debriefings and offering formal organisational support can be beneficial to their recovery. In an era of scarce resources, developing multidisciplinary second victim support programmes that align with existing organisational infrastructure can maximise second victims’ coping skills. Communicating and collaborating with institutions that have existing or emerging programmes can be useful in the early stages of programme development.
As patient safety and quality leaders, we have an obligation to take care of our own. How has your organisation been supportive of the second victim?
Cite this as: BMJ 2015;350:h1982
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.