The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Rodriquez J, Scott SD. Jt Comm J Qual Patient Saf. 2018;44:137-145.
Clinicians who experience emotional distress after adverse events or medical errors are referred to as second victims. Researchers surveyed health care providers whose career choices were impacted by involvement in an adverse event. In keeping with prior research, respondents reported a lack of support after the event.
Wu AW, Shapiro J, Harrison R, et al. J Patient Saf. 2020;16:65-72.
Word choice can impact buy-in for programs and integrating concepts across an organization. This review examines the term "second victim" as a label for health professionals involved in adverse events. The authors explore both constructive and negative reactions to the term and suggest that context and culture affect the appropriateness of its use.
Mira JJ, Lorenzo S, Carrillo I, et al. Int J Qual Health Care. 2017;29:450-460.
This review study examined policies to address the consequences of adverse events for patients, providers, and organizations. The methods included focus groups and a literature review. The team generated recommendations such as involving patients in event investigation, providing time away from usual work for second victims, and establishing a crisis plan for organizations.
Burlison JD, Quillivan RR, Scott SD, et al. J Patient Saf. 2021;17:195-199.
Health care organizations are increasingly recognizing the importance of providing support to second victims. In this survey study, researchers found that when respondents perceived their organization as supportive to second victim distress, they were less likely to express a desire to leave their job or to require time away from work. The authors point out that this is the first study to look at the impact of the second victim experience on work-related outcomes.
Quillivan RR, Burlison JD, Browne EK, et al. Jt Comm J Qual Patient Saf. 2016;42:377-386.
The second victim 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 victim experiences.
Scott SD, McCoig MM. J Healthc Risk Manag. 2016;35:6-13.
Health care workers who experience emotional consequences after being involved in a medical error are known as second victims. This commentary reviews the stages of recovery that such health care workers experience, determined by a hospital-based program to provide immediate support for second victims. A PSNet perspective offers insights from one of the authors about this program.
Burlison JD, Scott SD, Browne EK, et al. J Patient Saf. 2017;13:93-102.
The second victim 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, the SVEST, to examine clinicians' experiences with errors and evaluate the effectiveness of approaches to aid second victims.
Morris DS, Schweickert W, Holena DN, et al. Resuscitation. 2012;83:1434-7.
Rapid response events led by senior residents resulted in similar patient outcomes compared with those run by intensive care unit attending physicians, in this retrospective study at a large academic medical center.
Scott SD, Hirschinger LE, Cox KR, et al. Jt Comm J Qual Saf. 2010;36:233-240.
Rapid response systems (RRS) continue to penetrate hospitals nationally as a method to rescue patients experiencing imminent clinical deterioration. This study takes the same model and describes the context for and development of an innovative RRS to care for the second victim—a health care provider involved in an unanticipated adverse event, medical error, or patient-related injury. The authors surveyed faculty and staff at their institution and found that 39% were familiar with the term second victim and 30% reported personal problems in the past 12 months resulting from their involvement in a patient safety event. More than 80% of respondents expressed a desire for internal rather than external support when needing assistance. Early learnings from a second victim RRS are described, including training of "clinician lifeguards" and monitoring of the interventions. A past AHRQ WebM&M commentary explored how providers recover from their involvement in medical errors.
Sarani B, Sonnad SS, Bergey MR, et al. Crit Care Med. 2009;37:3091-6.
Rapid response systems serve an important patient safety function in hospitals by helping detect systematic problems in care, and emerging evidence indicates that such teams may improve some clinical outcomes. This study evaluated the views of frontline providers—bedside nurses and resident physicians—toward a rapid response team (RRT). Both groups agreed that the presence of the RRT improved patient safety, and both also felt that the RRT did not adversely affect their educational experience or patient care skills. These findings have been previously demonstrated for nurses. Interestingly, both nurses and residents who had more experience with the RRT felt more positively about its effects. The RRT in this study consisted of a critical care nurse, a respiratory therapist, and a pharmacist with physician backup.