Impact of System Failures on Healthcare Workers
The March 2022 conviction of RaDonda Vaught, a former nurse, was noted through the healthcare community. Vaught was found guilty of criminally negligent homicide and abuse of an impaired adult when a medication error resulted in a patient death in 2017. The news of Vaught’s conviction led healthcare professionals to reflect on the impact that the conviction may have on the healthcare system, safety failure reporting, and the culture of safety in many healthcare systems. In the wake of the guilty verdict, many organizations released public statements against the criminalization of medical errors based on the impact it could have on the disclosure of errors and near miss events.
Catastrophic safety events, like medication errors, are almost never caused by isolated errors committed by individuals. Most adverse events result from a series of circumstances in environments with underlying system flaws and failure points. In a culture of safety, health systems understand and acknowledge the high-risk and complex nature of providing care to patients. These health systems will also maintain a just culture in which they promote a blame-free environment so individuals can report errors or near misses without fear of negative consequences, reprimand, or punishment. Health systems that maintain a culture of safety also encourage collaboration among staff to identify opportunities to improve patient safety and have an organizational commitment to provide resources that will help address safety concerns and further prevent system failures.
The impact that system failures may have on the healthcare workforce was a major theme of articles featured on PSNet in 2022, as the patient safety community explored ways to support healthcare workers involved in adverse events and mitigate the impact that adverse events may have on employees moving forward. Members of the PSNet team reviewed relevant articles reported in AHRQ’s PSNet Collection throughout 2022 and consulted with George Zangaro, PhD, RN, FAAN, a subject matter expert in the nursing workforce. Key themes are highlighted in the following sections of this Year in Review.
Impact of System Failures on Healthcare Workers
Healthcare workers deliver care as part of complex systems that are ripe for errors and adverse events. High stakes patient care must be provided despite complex patient conditions, incomplete information, inadequate support, escalating workloads and administrative burdens, chronic underinvestment in public health infrastructure, and moral injury from being unable to provide the care patients need.1 Healthcare workers must know when to rigidly follow protocols and when adaptation is necessary. Although healthcare workers may make errors, given the complexity of healthcare delivery, adverse events are often the culmination of many different contributory factors and systems failures. Healthcare workers generally enjoy challenges and take pride in providing the best patient care, these systemic stresses can contribute to frustration, and if they contribute to patient harm, they may contribute to healthcare worker distress.2
Regardless of whether an error contributed to an adverse event, healthcare workers involved in unanticipated adverse events are often traumatized by the event. Healthcare workers involved in a medical error or adverse event may experience a range of emotional and psychological trauma including stress, anxiety, depression, guilt, and shame. Stress and anxiety could lead to disturbances, nightmares, and difficulty concentrating, while depression could result in feelings of sadness, hopelessness, helplessness, and even suicide. Healthcare workers may blame themselves for causing harm to the patient, experience a loss of confidence and self-esteem, and further question their own judgment and decision-making capabilities.
Healthcare staff involved in an adverse event can develop post-traumatic stress disorder (PTSD) with flashbacks, nightmares, and avoidance behaviors related to the event. The traumatic effects and negative feelings after involvement in an adverse event can also lead to professional isolation, and staff changing their roles or even changing professions. Healthcare workers may also be concerned about loss of employment or legal consequences.
The cumulative effect of system failures can contribute to decreased morale and burnout of the workforce. While burnout manifests in individuals, it is fundamentally rooted in systems. Healthcare worker burnout is a national crisis and is caused by many different factors, including moral injury from being unable to provide the care patients need.3 Manifestations of burnout can be physical, such as exhaustion and insomnia, or psychological, including fatigue and decreased productivity. Burnout can also manifest in individuals emotionally, resulting in a lack of motivation, lack of empathy for patients, a sense of failure, disengagement, and a decreased sense of personal accomplishment. Emotional distress among staff can become a patient safety hazard; staff in distress may find it difficult to provide optimal care to patients. There may be behavioral manifestations as well, where staff are more likely to avoid the workplace, withdraw from the professional setting, or seek substance use or misuse.3,4
After being involved in an adverse event, healthcare workers may subsequently experience a fear of reporting errors and a lack of psychological safety. Staff who are involved in continual system failures may want to avoid bringing attention to more problems. Healthcare workers seeking to report errors, adverse events, or hazards often encounter a culture of fear or blame and may fear retaliation, punishment, or reprisal.
Recommendations for Supporting Healthcare Workers
Because adverse events and harms are the result of systemic failures, the central approach to supporting healthcare workers impacted by these events should be at a systems level. In addition to addressing systemic causes of specific adverse events as they are identified, organizations can improve efforts and develop ways to support healthcare workers including encouraging transparent and safe error reporting, enhancing a culture of teamwork, using data to mitigate risk, and counteracting burnout.
Create Transparency Around and a Safe Space for Error Reporting
Reinforcing a culture of safety is key to supporting healthcare workers because errors and adverse events are the result of system failures. It is important to have a strong culture of safety in place, with clear policies and procedures, effective communication and feedback, ongoing training and education, and opportunities for continuous improvement.5 To overcome the fear of reporting and promote a culture of transparency and accountability, healthcare organizations must create a safe and nonpunitive environment for reporting, build trust with healthcare workers so that they feel comfortable reporting, provide training and education on the reporting process, and demonstrate the importance of learning from errors rather than punishing those who make them. Lessons learned from adverse events could help improve future patient safety. Identifying and mitigating hazards helps healthcare systems identify ways to avoid repeating errors, prevent further harm, and implement improvements. Engaging staff in the development and implementation of the patient safety program at an organization could further empower staff and help them feel comfortable with reporting in the future.
Assess Staffing Levels and Enhance a Culture of Teamwork
Recognizing that there are constant risks of adverse events, health systems can develop opportunities to sustain a team environment and decrease the incidence of staff turnover. Teamwork and the interdependent work of healthcare workers across professions contribute to improved patient safety. Healthcare delivery necessitates strong communication and collaboration skills for a productive work environment. Strengthening a teamwork environment and ensuring proper staffing levels will support healthcare workers and improve patient safety.
Capture and Use Data to Mitigate Risk and Support Learnings from Events
A culture of safety is a culture of continuous learning and improvement with the goal of preventing future errors. Learning from both successful and unsuccessful outcomes is key in understanding processes and promote safe care. For this reason, health systems must integrate data-driven resolutions to address patient safety. All system designs require continuous monitoring and improvement to reduce risk and ensure positive patient outcomes. Organizations can adopt a systematic approach to gather and analyze data, identify system failures, and decrease the risk of future failure and optimize conditions that support safe patient care. Consistent collection of data may allow continuous monitoring and early recognition of system failure.
Addressing burnout is paramount to ensuring support for healthcare workers involved in adverse events by ensuring that resources are available for reducing burnout and continuously engaging staff. Burnout can impact workers at all levels, including those who are not direct care providers such as quality improvement and patient safety professionals.6 High levels of employee engagement is recognized as an indicator of a culture of safety and is considered to be an important factor in promoting patient safety. When employees are engaged and invested in their work, they are more likely to be motivated to identify and report safety concerns and to take active steps to prevent errors. Engaged employees are also more likely to be knowledgeable about safety protocols and to follow them consistently. Additionally, engaged employees may be more likely to work collaboratively and communicate effectively with their colleagues, which can help to reduce the risk of adverse events.
Support for Individual Healthcare Professionals Impacted by Adverse Events
In addition to the system-based recommendations for supporting healthcare workers, below are some suggestions to help individual healthcare workers cope with the impact of system failures. Although critically important, systemic approaches are often difficult to implement and slow to effect. In light of that, strategies to support individual healthcare workers in the near term are essential.
One primary way that healthcare organizations can support workers is to recognize the impact of system failures and adverse events on the healthcare staff involved and understand the different traumatic effects of involvement in an adverse event. Organizations should develop and establish resources to help traumatized workers cope with the emotional and psychological impacts of an adverse event; this may also prevent them from leaving the workforce. Healthcare systems should develop nonpunitive and easily accessible resources to help traumatized healthcare workers.
Create Awareness and Openness About Resources Available to Support Staff
In many cases, staff may recognize the need for support but may be unaware of the resources that are available to them or their colleagues. Staff may also be afraid of repercussions from accessing these resources. Health systems can disseminate information about the availability of these resources internally. Peer support systems are a widely recognized method of helping healthcare workers deal with work-related stresses and trauma. Developing systems of peer support will help healthcare workers process trauma. One study showed that peer support programs positively impacted healthcare professionals’ perceptions of availability and quality of supportive resources after involvement in an adverse event; the study also showed that professionals had an improved view of adequate support after involvement in system failures. Organizations have used Schwartz Rounds to help to reduce the high levels of stress associated with healthcare delivery. Schwartz Rounds are facilitated, unit-based conversations during which staff can discuss the emotional aspect of patient care, typically based on a monthly theme. Staff members will share stories related to the theme; all staff can listen and discuss their own experiences.7 These rounds are utilized to support staff and allow them to share an experience about a patient’s care. In addition, this forum may promote team building, reduce feelings of isolation, and improve interdisciplinary communication.8
After an adverse patient care event, there are many ways to support healthcare workers to help mitigate traumatic effects, feelings of burnout, and fear of future reporting. While 2022 marked a year in which many health systems reaffirmed their commitment to improving patient safety and continuing to move toward a just culture, there is still room for growth and improvement to support staff members. As noted in the National Action Plan to Advance Patient Safety, culture, leadership and governance are foundational for advancing patient safety. The National Action Plan provides supplementary resources to help organizations to implement recommendations from the plan. As research has shown throughout the year, peer support systems and workforce management can help staff feel supported.
Editor’s Note: Many resources refer to healthcare workers involved in a medical error as the “second victim.” While the term is internationally recognized, the term is also widely disputed, given its potential insensitivity to patients. Because of this disagreement, we avoid the use of the term and refer to the traumatic effects that are felt by healthcare workers after involvement in a system failure.
* The views, analyses, and conclusions expressed in this article are those of the authors and do not necessarily reflect the official policy or positions of the American Association of Colleges of Nursing.
1. Murthy VH. Confronting health worker burnout and well-being.N Engl J Med. 2022;387(7):577-579. doi:10.1056/NEJMp2207252
2. Quillivan RR, Burlison JD, Browne EK, Scott SD, Hoffman JM. Patient Safety Culture and the Second Victim Phenomenon: Connecting Culture to Staff Distress in Nurses.Jt Comm J Qual Patient Saf. 2016;42(8):377-386. doi:10.1016/s1553-7250(16)42053-2
3. Dulko D, Zangaro GA. Comparison of factors associated with physician and nurse burnout. Nurs Clin North Am. 2022;57(1):53-66.
4. Zangaro GA, Dulko D, Sullivan D, Weatherspoon D, White KM, Hall VP, Sequellati R, Donnelli A, James J, Wilson DR. Systematic review of burnout in U.S. nurses. Nurs Clin North Am. 2022;57(1):1-20.
5. Armada A. Just culture: a safety imperative. ACHE blog. Accessed November 23, 2022. https://www.ache.org/blog/2022/just-culture-a-safety-imperative
6. National Association for Healthcare Quality. Healthcare quality and safety workforce report: new imperatives for quality and safety mean new imperatives for workforce development. Accessed December 7, 2022. https://nahq.org/resources/healthcare-quality-and-safety-workforce-report-new-imperatives-for-quality-and-safety-mean-new-imperatives-for-workforce-development/
7. The Schwartz Center for Compassionate Healthcare. Schwartz rounds and membership. Accessed January 18, 2023. https://www.theschwartzcenter.org/programs/schwartz-rounds/
8. Taylor C, Xyrichis A, Leamy MC, Reynolds E, Maben J. Can Schwartz Center Rounds support healthcare staff with emotional challenges at work, and how do they compare with other interventions aimed at providing similar support? A systematic review and scoping reviews. BMJ Open. 2018;8(10):e024254. doi:10.1136/bmjopen-2018-024254