System planning for modern-day Just Culture to mitigate worker distress and second victim response.

Joanna R Sells; Irene Cole; Charlie Dharmasukrit; Amy J. Brown; Christine Rovinski-Wagner; Tamara L Tasseff

Commentary

System planning for modern-day Just Culture to mitigate worker distress and second victim response.

November 29, 2023

Sells JR, Cole I, Dharmasukrit C, et al. BMJ Lead. 2023;Epub Sep 21.

View more articles from the same authors.

Involvement in a patient safety event can result in serious psychological consequences for healthcare workers. This article describes the importance of proactive organizational planning to protect and support healthcare workers after involvement in a patient safety event and provides several examples of successful peer-support programs, such as the Resilience in Stressful Events (RISE) program or the Center for Professionalism and Peer Support.

PubMed citation

Available at

Related Resources From the Same Author(s)

Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety.

July 19, 2023

Families as partners in hospital error and adverse event surveillance.

March 8, 2017

Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.

December 19, 2018

Changes in medical errors after implementation of a handoff program.

November 12, 2014

Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: a multisite longitudinal assessment.

February 15, 2023

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

Recommendations to improve the usability of drug–drug interaction clinical decision support alerts.

November 25, 2015

Safety of overlapping surgery at a high-volume referral center.

January 18, 2017

Operating room traffic as a modifiable risk factor for surgical site infection.

January 11, 2017

Automated identification of postoperative complications within an electronic medical record using natural language processing.

August 31, 2011

Qualitative content analysis of coworkers' safety reports of unprofessional behavior by physicians and advanced practice professionals.

April 18, 2018

Surgical specimen management: a descriptive study of 648 adverse events and near misses.

October 5, 2016

ASPEN Safe Practices for Enteral Nutrition Therapy.

December 14, 2016

Risk factors associated with medication ordering errors.

December 16, 2020

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial.

March 1, 2023

Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses.

April 13, 2016

A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.

February 2, 2011

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

The association between patient safety indicators and medical malpractice risk: evidence from Florida and Texas.

July 26, 2017

Perspectives about racism and patient-clinician communication among black adults with serious illness.

July 26, 2023

Blurring the boundaries: scenario-based simulation in a clinical setting.

June 8, 2005

Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals.

January 20, 2016

Association of postoperative readmissions with surgical quality using a Delphi consensus process to identify relevant diagnosis codes.

May 16, 2018

Complexity and challenges of the clinical diagnosis and management of Long COVID.

November 30, 2022

Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug event triggers designed for the outpatient setting.

June 24, 2015

Development of trigger tools for surveillance of adverse events in ambulatory surgery.

November 10, 2010

Applying trigger tools to detect adverse events associated with outpatient surgery.

March 16, 2011

Association of household opioid availability and prescription opioid initiation among household members.

January 10, 2018

Response of practicing chiropractors during the early phase of the COVID-19 pandemic: a descriptive report.

July 8, 2020

Effect of genetic diagnosis on patients with previously undiagnosed disease.

November 7, 2018

A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program.

April 26, 2023

Joy in medical practice: clinician satisfaction in the Healthy Work Place trial.

November 1, 2017

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS).

February 12, 2020

Racial and ethnic differences in emergency department pain management of children with fractures.

April 22, 2020

Surgical team training: the Northwestern Memorial Hospital experience.

February 25, 2009

Clinical impact and economic burden of hospital-acquired conditions following common surgical procedures.

February 13, 2019

Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.

June 8, 2016

The challenges in monitoring and preventing patient safety incidents for people with intellectual disabilities in NHS acute hospitals: evidence from a mixed-methods study.

October 15, 2014

Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis.

May 20, 2020

Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture.

September 2, 2020

Consensus building for development of outpatient adverse drug event triggers.

June 15, 2011

Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services.

August 14, 2019

Accuracy of infection reporting in US nursing home ratings.

August 9, 2023

Communication failure in the operating room.

November 3, 2010

Effects of nursing rounds on patients' call light use, satisfaction, and safety.

September 20, 2006

Multilevel factors associated with time to biopsy after abnormal screening mammography results by race and ethnicity.

July 6, 2022

Dying for the weekend: a retrospective cohort study on the association between day of hospital presentation and the quality and safety of stroke care.

July 25, 2012

Electronic health record-based prediction models for in-hospital adverse drug event diagnosis or prognosis: a systematic review.

March 29, 2023

Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents.

October 6, 2010

Exposure to media information about a disease can cause doctors to misdiagnose similar-looking clinical cases.

March 12, 2014

Experiences of transgender people reviewing their electronic health records, a qualitative study.

June 29, 2022

The compliance with a patient safety bundle for management of placenta accreta spectrum.

October 16, 2019

Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders.

July 26, 2017

Identifying organizational cultures that promote patient safety.

November 18, 2009

Comparing safety climate between two populations of hospitals in the United States.

October 14, 2009

Relationship of hospital organizational culture to patient safety climate in the Veterans Health Administration.

March 25, 2009

An overview of patient safety climate in the VA.

April 9, 2008

Exploring the causes of adverse events in hospitals and potential prevention strategies.

February 24, 2010

Physician perspectives on responding to clinician-perpetuated interpersonal racism against Black patients with serious illness.

September 13, 2023

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.

March 17, 2021

Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis.

May 24, 2017

Effects of patient safety culture interventions on incident reporting in general practice: a cluster randomised trial.

June 17, 2015

Improving patient safety culture in primary care: a systematic review.

September 7, 2016

Preventing home medication administration errors.

March 14, 2022

Physician perspectives on addressing anti-Black racism.

February 14, 2024

An epistemology of patient safety research: a framework for study design and interpretation.

June 18, 2008

Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology.

October 26, 2011

Eradicating central line–associated bloodstream infections statewide: the Hawaii experience.

November 16, 2011

Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled-nursing facility.

July 21, 2021

Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward.

September 9, 2009

Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.

January 30, 2005

Medication errors in the homes of children with chronic conditions.

January 30, 2005

Medication errors among acutely ill and injured children treated in rural emergency departments.

May 2, 2007

Failure mode and effects analysis: a comparison of two common risk prioritisation methods.

May 4, 2016

Sleep, sleepiness, fatigue, and performance of 12-hour–shift nurses.

August 3, 2016

What is preventable harm in healthcare? A systematic review of definitions.

August 8, 2012

A multicenter collaborative approach to reducing pediatric codes outside the ICU.

March 7, 2012

Exploring the intersection of structural racism and ageism in healthcare.

December 7, 2022

Attitudes to teamwork and safety in the operating theatre.

June 28, 2006

Differential safety between top-ranked cancer hospitals and their affiliates for complex cancer surgery.

April 24, 2019

Impact of online education on intern behaviour around Joint Commission national patient safety goals: a randomised trial.

June 27, 2012

International evaluation of an AI system for breast cancer screening.

January 29, 2020

The effect of a clinical decision support for pending laboratory results at emergency department discharge.

February 13, 2019

Parent perceptions of children's hospital safety climate.

April 17, 2013

Are parents who feel the need to watch over their children's care better patient safety partners?

December 6, 2017

Medication reconciliation campaign in a clinic for homeless patients.

April 4, 2012

Self-reported violations during medication administration in two paediatric hospitals.

May 16, 2012

To do no harm - and the most good - with AI in health care.

March 13, 2024

Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review.

May 12, 2021

Children and the opioid epidemic: age-stratified exposures and harms.

October 21, 2020

Trends and patterns in reporting of patient safety situations in transplantation.

February 10, 2016

Excess cost and length of stay associated with voluntary patient safety event reports in hospitals.

January 28, 2009

The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada.

March 6, 2005

Reporting and disclosing medical errors: pediatricians' attitudes and behaviors.

February 7, 2007

Pharmacists in pharmacovigilance: can increased diagnostic opportunity in community settings translate to better vigilance?

July 9, 2014

Use of the revised second victim experience and support tool to examine second victim experiences of respiratory therapists.

April 26, 2023

Do patients' disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment.

March 23, 2016

The development and piloting of the Ambulatory Electronic Health Record Evaluation Tool: lessons learned.

March 17, 2021

How gender shapes interprofessional teamwork in the operating room: a qualitative secondary analysis.

January 26, 2022

Related Resources

Bad behavior in healthcare: an insidious threat to patients, staff, and organizations.

April 17, 2024

Support and recovery strategies for second victims.

April 3, 2024

Annual Perspective

Ensuring Patient and Workforce Safety Culture in Healthcare

March 27, 2024

Scoping review of the second victim syndrome among surgeons: understanding the impact, responses, and support systems.

March 27, 2024

Creating a just culture in the perioperative setting.

March 13, 2024

Power of saying ‘I Don’t Know’: psychological safety and participatory strategies for healthcare leaders.

March 13, 2024

Investigating workplace support and the importance of psychological safety in general surgery residency training.

March 13, 2024

Nurse leader attitudes and beliefs regarding medical errors.

March 6, 2024

Interventions to support nurses as second victims of patient safety incidents: a qualitative study of nurse managers' perceptions.

February 7, 2024

Psychological safety as a new ACGME requirement: a comprehensive all-in-one guide to radiology residency programs.

November 8, 2023

Use of the Second Victim Experience and Support Tool (SVEST) to assess the impact of a departmental peer support program on anesthesia professionals' second victim experiences (SVEs) and perceptions of support two years after implementation.

November 8, 2023

React, reframe and engage. Establishing a receiver mindset for more effective safety negotiations.

November 8, 2023

Supporting nurses in acute and emergency care settings to speak up.

November 8, 2023

Achieving a successful patient safety program with implementation of a harm reduction strategy.

October 25, 2023

Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive.

October 18, 2023

Judy Smetzer Just Culture Champion Scholarships.

August 16, 2023

The things we carry: the scope and impact of second victim syndrome.

August 2, 2023

Improving Patient Safety Culture – A Practical Guide.

August 2, 2023

Patient, carer and family experiences of seeking redress and reconciliation following a life-changing event: systematic review of qualitative evidence.

August 2, 2023

Emotional responses and support needs of healthcare professionals after adverse or traumatic experiences in healthcare-evidence from seminars on peer support.

June 28, 2023

Systems approach to suicide prevention: strengthening culture, practice, and education.

June 28, 2023

Individual characteristics that promote or prevent psychological safety and error reporting in healthcare: a systematic review.

May 10, 2023

Listening, Learning, Responding to Concerns.

April 12, 2023

What's changed 1 year after RaDonda Vaught's conviction?

April 12, 2023

Normalization of deviance is contrary to the principles of high reliability.

April 12, 2023

The influence of professional identity on how the receiver receives and responds to a speaking up message: a cross-sectional study.

March 29, 2023

Perspectives on Safety

Annual Perspective

Impact of System Failures on Healthcare Workers

March 21, 2023

Lessons learned from the RaDonda Vaught ruling.

March 1, 2023

Health care professionals' perceptions of unprofessional behaviour in the clinical workplace.

March 1, 2023

An evidence and consensus-based definition of second victim: a strategic topic in healthcare quality, patient safety, person-centeredness and human resource management.

February 15, 2023

See More About The Topic

Psychological and Social Complications

Second victims

Just Culture

System planning for modern-day Just Culture to mitigate worker distress and second victim response.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

System planning for modern-day Just Culture to mitigate worker distress and second victim response.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site