Kandasamy S, Vanstone M, Colvin E, et al. J Eval Clin Pract. 2021;27:236-245.
Physicians often experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. Based on in-depth interviews with emergency, internal, and family medicine physicians, this qualitative study explores how physicians experience and learn from preventable medical errors. In addition to exploring themes around the physician’s emotional growth and professional development, the authors discuss the value of sharing and learning from these experiences for colleagues and trainees.
Tannenbaum SI, Traylor AM, Thomas EJ, et al. BMJ Qual Saf. 2021;30:59-63.
This article summarizes evidence-based recommendations for team-based patient care during the COVID-19 pandemic. These recommendations focus on team functioning, safety culture, and resilience. The authors discuss how individual-, team-, and organizational-level stressors, as well as work-life stressors, can affect team performance.
The International Society for Quality in Health Care. March - May 2020.
The COVID-19 pandemic is a worldwide crisis that requires organizations, governments, and individuals to draw from the collective experience and rapidly improve practice. This series of webinars discuss a variety of foci to share experience from the field. Topics covered include human factors engineering, clinician support, and communication.
Srinivasa S, Gurney J, Koea J. JAMA Surg. 2019;154:451-457.
As many as half of all clinicians may be involved in a serious adverse event during their career, and these events may have profound professional consequences. This systematic review examined the effect of patient complications on surgeons' well-being. Patient complications had significant adverse consequences for surgeons' emotional health, to which surgeons responded with coping mechanisms ranging from adaptive (discussing cases with colleagues or utilizing professional support) to maladaptive (alcohol or substance use). Studies reported varying perceptions of institutional support. Many surgeons derived benefit from the support of trusted mentors or senior colleagues after a serious patient complication, but lack of formal organizational support was commonly noted. Surgeons reported taking various corrective actions after a complication, such as personal development and system-level quality improvement efforts. The authors make several recommendations for helping surgeons after complications, including developing formal structures to aid surgeons in the coping process. Books by British neurosurgeon Dr. Henry Marsh and patient safety leader Dr. Atul Gawande explore the professional and personal consequences of adverse events in vivid detail.
Researchers surveyed recent nursing graduates to understand the role of nursing education in mitigating the second victim effect. Respondents felt pressured not to make mistakes, and those who described an error frequently experienced the second victim effect. The authors suggest that nursing education should better prepare nurses to handle unanticipated outcomes and the associated emotional response.
Gold KJ, Andrew LB, Goldman EB, et al. General Hospital Psychiatry. 2016;43.
Burnout, stress, and personal challenges can affect clinicians' ability to provide safe care. This article explores factors that prevent clinicians from seeking support and provides suggestions for organizations to encourage health care providers to solicit help, such as establishing a culture of wellness, second victim initiatives, substance abuse assistance, and domestic violence programs.
The second victim phenomenon has been well-documented in health care, but the problem has rarely been studied in certain specialties. Reviewing the literature on how medical error can affect nurse anesthetists, this commentary describes the development of a curriculum for this specialty group which focuses on definitions, risks, barriers, and interventions.
Krzan KD, Merandi J, Morvay S, et al. Am J Health Syst Pharm. 2015;72:563-7.
The term "second victims" was coined to describe clinicians who commit errors, acknowledging the significant emotional impact that errors can have on the clinicians involved. A structured program to provide immediate support to clinicians affected by medical errors was well received by the pharmacy staff at a pediatric hospital.
Scott SD, Hirschinger LE, Cox KR, et al. Qual Saf Health Care. 2009;18:325-30.
Committing a medical error can cause profound emotional distress for clinicians, to the point that clinicians have been called the "second victim" of errors. This study examined how clinicians recover from the psychological stress of being involved in an error, and discusses the factors associated with recovery. A previous AHRQ WebM&M case commentary also explores how providers recover from such errors.
An elderly man with COPD and end-stage congestive heart failure was admitted for increasing shortness of breath, due to a pleural effusion. A resident performed a thoracentesis on the wrong side, and the patient developed a pneumothorax and died. The resident disclosed the error but was devastated.
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