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- United States of America
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Meeting/Conference > Kansas Meeting/Conference
Second Victim Train-the-Trainer Workshop.
Center for Patient Safety and University of Missouri. November 10, 2017; Saint Luke's North Hospital, Barry Road, Kansas City, MO.
Second victims are clinicians who experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. This workshop will explore strategies to build an organizational program that addresses individual stages of recovery and trains peers to participate in that process. Sue Scott will lead the session.
Journal Article > Study
Exploring the experience of nurse practitioners who have committed medical errors: a phenomenological approach.
Delacroix R. J Am Assoc Nurse Pract. 2017 Apr 27; [Epub ahead of print].
This qualitative interview study of nurse practitioners who had made errors found that they experience complex reactions, including self-blame, concern for the patient, worries about their professional future, and feelings of failure. These results echo prior work about health care team members as second victims of medical errors.
Journal Article > Review
Correlates of the third victim phenomenon.
Russ MJ. Psychiatr Q. 2017 Mar 25; [Epub ahead of print].
A sentinel event affects patients, their families, clinicians involved, and the organization. This review article describes a serious incident at a hospital and explored changes in decision making, discharge rate, and peer observation after the event to illustrate the organization as the third victim.
Journal Article > Study
The surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) study.
Han K, Bohnen JD, Peponis T, et al. J Am Coll Surg. 2017 Jan 16; [Epub ahead of print].
Health care providers who experience psychological harm associated with adverse events are often referred to as second victims. This survey of surgeons found that the majority who could recall an intraoperative adverse event experienced negative emotions, and only a minority accessed formal support systems. This work emphasizes the need to build systems to provide support for second victims.
Journal Article > Review
Huddles and debriefings: improving communication on labor and delivery.
McQuaid-Hanson E, Pian-Smith MCM. Anesthesiol Clin. 2017;35:59-67.
Labor and delivery units are high-risk environments where one miscommunication can lead to care breakdowns. This commentary discusses huddles as a strategy to reduce communication errors and debriefings as opportunities to learn from incidents and provide support for second victims.
Journal Article > Study
The effects of the second victim phenomenon on work-related outcomes: connecting self-reported caregiver distress to turnover intentions and absenteeism.
Burlison JD, Quillivan RR, Scott SD, Johnson S, Hoffman JM. J Patient Saf. 2016 Nov 2; [Epub ahead of print].
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.
Journal Article > Study
Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study.
Edrees H, Connors C, Paine L, Norvell M, Taylor H, Wu AW. BMJ Open. 2016;6:e011708.
Health care workers who experience distress following adverse events are considered second victims. This study described the implementation of a peer support program for second victims. The program initially received few calls for assistance, and most adverse events for which health care workers—predominantly nurses—requested support were not related to medical errors.
Journal Article > Study
Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses.
Quillivan RR, Burlison JD, Browne EK, Scott SD, Hoffman JM. 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.
Journal Article > Commentary
Care at the point of impact: insights into the second-victim experience.
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.
Journal Article > Commentary
Design of an evidence-based "second victim" curriculum for nurse anesthetists.
Daniels RG, McCorkle R. AANA J. 2016;84:107-113.
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.
Journal Article > Study
Assessing the perceived level of institutional support for the second victim after a patient safety event.
Joesten L, Cipparrone N, Okuno-Jones S, DuBose ER. J Patient Saf. 2015;11:73-78.
Clinicians involved in errors are often termed second victims, as they experience significant emotional and professional consequences. Despite this widely known effect, this survey found that most nurses at a community teaching hospital did not feel that adequate support was available for clinicians whose patients experienced an adverse event.
Journal Article > Study
Risk managers' descriptions of programs to support second victims after adverse events.
White AA, Brock DM, McCotter PI, et al. J Healthc Risk Manag. 2015;34:30-40.
This AHRQ-funded study surveyed risk managers about programs that provide support for clinicians involved in adverse events, who are often referred to as second victims. Approximately three-quarters of organizations reported having a support program, but they varied widely in structure and staffing. Many of the programs lacked elements recommended by national standards, suggesting significant room for improvement.
Journal Article > Study
Implementation of a "second victim" program in a pediatric hospital.
Krzan KD, Merandi J, Morvay S, Mirtallo J. Am J Health Syst Pharm. 2015;72:563-567.
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.
Journal Article > Study
The second victim experience and support tool: validation of an organizational resource for assessing second victim effects and the quality of support resources.
Burlison JD, Scott SD, Browne EK, Thompson SG, Hoffman JM. 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 to examine clinicians' experiences with errors and evaluate the effectiveness of approaches to aid second victims.
Newspaper/Magazine Article
"Second victim" casualties and how physician leaders can help.
MacLeod L. Physician Exec. Jan-Feb 2014;40:8-12.
Second victims are clinicians who experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. This magazine article discusses the need for hospitals to provide care for these clinicians and spotlights the role of physician leaders in promoting and facilitating support programs.
Journal Article > Commentary
Supporting second victims of patient safety events: shouldn't these communications be covered by legal privilege?
de Wit ME, Marks CM, Natterman JP, Wu AW. J Law Med Ethics. 2013;41:852-858.
Reviewing physician–patient privilege laws in five states, this commentary illustrates substantial variation in legal protections provided for second victim programs and recommends clear legislation for clinicians who seek support.
Book/Report
Second Victim: Error, Guilt, Trauma, and Resilience.
Dekker S. Boca Raton, FL: CRC Press; 2013. ISBN: 9781466583412.
This book covers how to investigate patient safety incidents while simultaneously providing support for second victims.
Newspaper/Magazine Article
The 'second victims' of medication errors begin to gain support.
Blum K. Pharm Pract News. November 2011.
Exploring the impact of medication errors on clinicians, this article discusses efforts to support second victims affected by medical error.
Journal Article > Review
Health care professionals as second victims after adverse events: a systematic review.
Seys D, Wu AW, Van Gerven E, et al. Eval Health Prof. 2013;36:135-162.
Focusing on health care providers as the second victims of adverse events, this review explores the prevalence of second victims, the impact of the error, and individual coping strategies.
Journal Article > Commentary
How to develop a second victim support program: a toolkit for health care organizations.
Pratt S, Kenney L, Scott SD, Wu AW. Jt Comm J Qual Patient Saf. 2012;38:235-240.
This commentary describes the development of a toolkit to help hospitals create and implement support programs for second victims of medical error.
