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Zaheer S, Ginsburg LR, Wong HJ, et al. BMC Nurs. 2021;20(1):134.
Fostering a positive safety culture is essential to delivery of safe care. This mixed-methods study of nurses and non-physician health professionals found that staff perceptions of senior leadership, teamwork, and turnover intention were significantly associated with overall patient safety grade.
Klatt TE, Sachs JF, Huang C-C, et al. Jt Comm J Qual Patient Saf. 2021;Epub Sep 29.
This article describes the implementation of a peer support program for “second victims” in a US healthcare system. Following training, peer supporters assisted at-risk colleagues, raised awareness of second victim syndrome, and recruited others for training. The effectiveness of the training was assessed using the Second Victim Experience Support Tool. The most common event supported was inability to stop the progress of a medical condition, including COVID-19.
Stovall M, Hansen L. Worldviews Evid Based Nurs. 2021;18(5):264-272.
Clinicians who are involved in a patient safety incident often experience significant emotional consequences. This study found that nurses involved in an patient safety incident resulting in patient death were more likely to change jobs, consider leaving the profession, and have suicidal ideation, compared to nurses involved in incidents that did not result in patient harm.

Betsy Lehman Center. September 2021.

Clinicians involved in adverse events that harm patients can struggle to come to terms with error. This toolkit is designed to assist organizations in the development of initiatives to support clinicians and staff after an adverse event. Areas of focus include leadership buy-in, policy development, and training. An implementation guide is also provided.
Martin GP, Chew S, Dixon-Woods M. Soc Sci Med. 2021;287:114375.
Engaging patients and families in patient safety efforts and encouraging them to speak up about concerns is an ongoing healthcare priority. Based on narrative interviews with people raising and responding to concerns and complaints in six English National Health Service (NHS) organizations, this study explored how substandard responses to concerns and complaints can lead to organizational failures.
Grailey K, Leon-Villapalos C, Murray E, et al. BMJ Open. 2021;11(8):e046699.
Psychological safety enables staff to raise concerns, reduce mistakes and learn from errors. The majority of surveyed intensive care unit staff in three units within one trust in London reported feeling psychologically safe within their teams (e.g. being able to bring up problems). In a novel finding, this study identified potential negative consequences of psychological safety, including distraction and fatigue for team leaders.
Monazam Tabrizi N, Masri F. BMJ Open. 2021;11(8):e048036.
In this qualitative study, researchers interviewed 40 clinicians in high- and low-performing hospitals to better understand the barriers to effective organizational learning from medical errors. Findings from these interviews suggest that the primary barriers to active learning stem from social issues post-reporting – e.g., lack of trust or proactive engagement from management. The authors highlight the importance of fostering an organizational culture that encourages cooperation and collaboration between management and clinicians.
Jun J, Ojemeni MM, Kalamani R, et al. Int J Nurs Stud. 2021;119:103933.
Burnout among nurses can compromise safe patient care and lead to poor outcomes. This systematic review identified five organizational-level outcomes associated with nurse burnout – (1) patient safety, (2) quality of care, (3) nurses’ organizational commitment, (4) nurse productivity, and (5) patient satisfaction – and these themes were consistently inversely associated with outcome measures.
Kappes M, Romero‐García M, Delgado‐Hito P. Int Nurs Rev. 2021;Epub Jun 13.
Healthcare professionals who experience negative physical, psychological, or behavioral responses following an adverse event may be referred to as “second victims.” This review describes personal and organizational support strategies as well as barriers faced by second victims who are seeking support. The authors recommend further evaluation of support programs and implementation of support programs in Latin America.
Diabes MA, Ervin JN, Davis BS, et al. Ann Am Thorac Soc. 2021;18(6):1027-1033.
A key feature of safety culture is the psychological safety of all staff to feel empowered to speak up about errors or mistakes. In this study of intensive care unit clinicians, job strain, leader inclusiveness and perception of teamwork were associated with psychological safety. However, psychological safety was not associated with performance of either spontaneous breathing trials or lung-protective ventilation. Future research should focus on strategies to improve psychological safety in intensive care units.
Kruper A, Domeyer-Klenske A, Treat R, et al. J Surg Educ. 2021;78(3):1024-1034.
Physicians commonly experience adverse psychological outcomes after being involved in an adverse event. This mixed-methods study of health care providers in the Department of Obstetrics & Gynecology at one large academic hospital found that three-quarters of providers experienced symptoms of traumatic stress after involvement in an adverse event. Respondents reporting anxiety were more likely to be interested in peer-to-peer support programs, whereas those reporting symptoms of guilt preferred debriefing sessions.
Strid EN, Wåhlin C, Ros A, et al. BMC Health Serv Res. 2021;21(1).
Based on semi-structured interviews with healthcare workers in Sweden, the authors explored how individuals, team members and managers respond to critical incidents. Critical incidents are emotionally distressing for healthcare workers but teamwork and trust among teams can facilitate safe practices and help individuals overcome emotional distress. Respondents also highlighted the importance of organizational support for managing risks, individual closure, and providing support after an incident.
AHA Team Training. September 13--November 17, 2021.
The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This online series will prepare participants to guide their organizations through implementation of the TeamSTEPPS program. It is designed for individuals that are new to TeamSTEPPS processes.
Jones AM, Clark JS, Mohammad RA. Am J Health Syst Pharm. 2021;78(9):818-824.
Burnout has been a focus of numerous studies since the beginning of the COVID-19 pandemic; however, this is the first to focus on burnout and secondary traumatic stress (STS) among health system pharmacists. Nearly two thirds (65.3%) of respondents had a moderate to high likelihood of experiencing burnout and 51% had a high probability of STS. Due to the association between burnout and decreased patient safety, it is critical that health systems address pharmacist burnout appropriately.
Busch IM, Moretti F, Campagna I, et al. Int J Environ Res Public Health. 2021;18(10):5080.
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.
Shao Q, Wang Y, Hou K, et al. J Adv Nurs. 2021;Epub Jun 5.
Patient suicide in all settings is considered a never event. Nurses caring for the patient may experience negative psychological symptoms following inpatient suicide. This review identified five themes based on nurses’ psychological experiences: emotional experience, cognitive experience, coping strategies, self-reflection, and impact on self and practice. Hospital administrators should develop education and support programs to help nurses cope in the aftermath of inpatient suicide.  

Wands B. AANA J. 2021;89(2):168-174.

Healthcare professionals who experience emotional consequences after adverse events are often referred to as “second victims.” Targeted towards certified registered nurse anesthetists (CRNAs), this article discusses second victim experiences in anesthesiology and implications for anesthesia education and training.
Wu F, Dixon-Woods M, Aveling E-L, et al. Soc Sci Med. 2021;280:114050.
Reluctance of healthcare team members to speak up about concerns can hinder patient safety. The authors conducted semi-structured interviews with 156 participants (health system leadership, managers, healthcare providers, and staff) about policies, practice, and culture around voicing concerns related to quality and safety. Findings suggest that both formal and informal hierarchies can undermine the ability and desire of individuals to speak up, but that informal organization (such as personal relationships) can motivate and support speaking up behaviors.
Kakemam E, Chegini Z, Rouhi A, et al. J Nurs Manag. 2021;Epub May 10.
Clinician burnout, characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment, can result in worse patient safety outcomes. This study explores the association of nurse burnout and self-reported occurrence of adverse events during COVID-19. Results indicate higher levels of nurse burnout were correlated with increased perception of adverse events, such as patient and family verbal abuse, medication errors, and patient and family complaints. Recommendations for decreasing burnout include access to psychosocial support and human factors approaches.