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Perspectives on Safety > Interview
New Insights Into Apology and Disclosure Programs, April 2019
Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar Institute for Quality and Safety, and Adjunct Professor of Law at Loyola University-Chicago School of Law and the Beazley Institute for Health Law and Policy. An internationally recognized patient safety expert, he served as a lead architect for the Communication and Optimal Resolution (CANDOR) toolkit, supported by AHRQ. We spoke with him about lessons learned over the years regarding event reporting and his insights about building and disseminating communication-and-resolution programs.
ISMP Medication Safety Alert! Acute Care Edition. July 14, 2011;16:1-3.
Journal Article > Commentary
Hauk L. AORN J. 2018;107:P7-P9.
Involvement in an adverse event or error can have serious effects on health care workers. Spotlighting how operating room culture can deter individuals from seeking help, this commentary emphasizes the importance of assisting perioperative nurses immediately after a harmful mistake. The author reviews second victim support initiatives and tools and suggests involving perioperative nurses in support programs. A past PSNet perspective provides insight on the importance of second victim programs.
Journal Article > Study
Implementation of a second victim program in the neonatal intensive care unit: an interim analysis of employee satisfaction.
Merandi J, Winning AM, Liao N, Rogers E, Lewe D, Gerhardt CA. J Patient Saf Risk Manag. 2018;23:231-238.
Clinicians who experience negative emotional consequences after adverse events are considered second victims. This study evaluated health care provider satisfaction with a second victim peer support program in neonatal intensive care units. Many clinicians were unaware of the program but those who had used it expressed satisfaction. The authors conclude that specific efforts to raise awareness of and engagement with peer support for second victims is warranted.
Journal Article > Study
Kaur AP, Levinson AT, Monteiro JFG, Carino GP. J Crit Care. 2019;52:16-21.
The second victim effect has been used to describe the emotional impact that providers may experience when involved in a medical error, adverse event, or unanticipated patient outcome. In this survey study, researchers found that members of a critical care society frequently admitted to experiencing negative emotions such as blame and guilt when responding to questions involving scenarios of different types of errors. Nearly 70% of respondents suggested that team debriefings and talking with colleagues could help mitigate the second victim effect.
Journal Article > Review
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.