‘Second victim’ is controversial term used to describe health care professionals who experience continuing psychological harm after involvement in a medical error or adverse event. In this study, an expert panel reviewed existing definitions of ‘second victim’ in the literature and proposed a new consensus-based definition.

Medical errors should be examined in the context of system failure to generate lasting opportunities for learning and improvement. This commentary discusses the AHRQ 2022 report entitled Diagnostic Errors in the Emergency Department: a Systematic Review and suggests a focus on care delivery processes over individuals, definitions, error rate review, and system design as noteworthy approaches to error reduction.

The COVID pandemic has increased demand and acceptance of remote care modalities. This commentary suggests that home monitoring is a promising telehealth approach and that its application could improve value while enhancing safety for hospital-at-home and other levels of home-based care patients.

… as one key component of good quality care. … Hannawa AF, Wu AW, Kolyada A, et al. The aspects of healthcare quality that are … study. Patient Educ Couns. Epub 2021 Oct 30. doi: 10.1016/j.pec.2021.10.016 …

… online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in … learning format. … Gleason KT, Commodore-Mensah Y, Wu AW, et al. Massive open online course (MOOC) learning … study. Nurse Educ Today. 2021;104:104984. doi: 10.1016/j.nedt.2021.104984. …

… data have potential to impact health care improvement in a variety of ways. This commentary examines the intersection … in at-risk patient populations if adopted. … Ibrahim SA, Pronovost PJ. Diagnostic errors, health disparities, and artificial intelligence: a combination for health or harm?  JAMA Health Forum. …

… J Am Med Inform Assoc … Clinical decision support systems are … research. … Morris AH, Stagg B, Lanspa M, et al. Enabling a learning healthcare system with automated computer … produce replicable and personalized clinician actions. J Am Med Inform Assoc. 2021;28(6):1330-1344. …

… J Patient Saf Risk Manag … The July effect is a phenomenon that presumably results in poor care due to the … these practitioners to provide the safest care possible. … Wu AW, Vincent C, Shapiro DW, et al. Mitigating the July …

Clinicians involved in unexpected patient outcomes can experience negative emotions and frequently need access to second victim support programs. This systematic review describing 12 second victim support programs identifies staff benefits, implementation challenges, and experiences of peer supporters. Affected staff and peer supporters reported the benefits of the programs. Challenges included blame culture, limited awareness of program existence, and lack of financial resources. Findings indicate a need for implementing new second victim support programs, promoting current programs, and monitoring peer supporters’ well-being.

Unanticipated adverse events harm not only patients, but also have the potential to cause psychological harm to the healthcare providers involved in the incident. This study investigated how Maryland hospitals currently support “second victims.” Even though all study participants agreed that organizations should offer support programs to second victims, they stated that several barriers exist, including stigma. Future research efforts should involve second victims themselves in order to identify barriers and facilitators, such as safety culture, to the use of organization support programs.

… Jt Comm J Qual Patient Saf … Prior research has identified racial … failures contributing to disparities, a commitment from health system leadership to address … care workers and leadership.   … Austin JM, Weeks K, Pronovost PJ. Health system leaders' role in addressing …

The Resilience in Stressful Events (RISE) program provides peer support for healthcare workers who are involved in an adverse event. RISE program volunteers surveyed in this study reported positive perceptions of program participation and personal empowerment.  

In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.

This editorial discusses priority areas for maintaining and promoting the well-being of the healthcare workforce during the COVID-19 pandemic. The authors discuss the importance of providing adequate personal protective equipment (PPE), supporting basic daily needs (e.g., provision of in-hospital food stores), ensuring frequent and visible communication, supporting mental and emotional well-being, addressing ethical concerns, promoting wellness, and showing gratitude for staff.

… N Engl J Med … This study randomized primary care practices across … ten health care systems to evaluate the effectiveness of a multifactorial intervention to prevent falls with injury , … strategy to prevent serious fall injuries. N Engl J Med . 2020;383(2):129-140. doi: 10.1056/NEJMoa2002183. Epub …

In this literature review, the authors identified patient-, clinician-, and institutional-level barriers to patient involvement in patient safety investigations. Potential strategies for overcoming barriers are also discussed, such as adopting a blame-free climate and enhancing clinician training in error disclosure and communication.

To address the negative psychological impacts faced by healthcare workers during the COVID-19 crisis, the authors of this commentary recommend three strategic principles for healthcare institutions responding to the pandemic: Encourage leadership to focus on resilience  Ensure that crisis communication provides both information and empowerment Create a continuum of staff support within the organization to address a surge in mental health concerns among healthcare workers.

… (4) directed leadership to implement successful change. … Wu AW, Dzau VJ. What can patient safety teach us about …

Adverse events can have significant psychological impacts on the providers involved and involvement in medical errors can increase risk of burnout among second victims. This study describes the nurse utilization of the Resilience in Stressful Events (RISE) peer support program. The authors found high awareness of the program among nurses, but low utilization. Nurses who had used the program reported greater resilience, but more burnout than those who had not.

… BMJ open quality … BMJ Open Qual … Root cause analysis is a fundamental approach to understanding how failures occur, …