Perspective

The Institute of Medicine's report on medical mistakes, To Err is Human, described surprising numbers of projected deaths as a result of preventable medical errors within health care systems.(1) Investigations of unanticipated clinical events often reveal experienced, well-intentioned clinicians surrounded by complex clinical conditions, poorly designed processes, and inadequate communication patterns.(2)

While the focus of the patient safety field has mostly been on improving systems of care, such systems include real people, and safety events may take an emotional toll. Frequently, clinicians review medical errors and understand what has unfolded, reacting with appropriate sadness and concern. Such errors occasionally result in an intense period of professional and personal anguish, even among the "strongest" caregivers.

Publications describing these experiences initially appeared in the literature as personal anecdotes describing powerful feelings of guilt, incompetence, or inadequacy following a medical error.(3-6) The suffering of caregivers in the face of a serious medical error has been termed the second victim phenomenon, initially by Wu.(7) Once the phenomenon was identified, it became clear that in most health care settings, caregivers have no one they can turn to for support and/or guidance in the face of a terrible, unanticipated, clinical outcome or medical mistake, often resulting in them suffering in silence.

Soon authorities began highlighting the importance of various forms of support to assist with healthy recovery for suffering clinicians.(8-14) White, for example, stressed the need for institutional commitment to address second victim needs and speculated that most facilities had untapped internal resources that could support clinicians.(15) Denham proposed the formalization of second victim "rights" in the aftermath of an unanticipated clinical event, so that an automatic institutional response was stimulated and the clinician would know what to expect.(16)

At University of Missouri Health Care (MUHC) system, patient safety event investigations convinced us that our clinicians were experiencing a tremendous amount of professional suffering following these unanticipated clinical events. To quantify the prevalence of the second victim phenomenon at MUHC, in 2007 we added two questions to an internal patient safety culture survey.(17) Almost one in seven staff members (175/1,160) reported they had experienced a patient safety event within the past year that caused personal problems such as anxiety, depression, or concerns about the ability to perform one's job. An alarming 68% of these clinicians reported they didn't receive institutional support.

As a result of these disturbing findings, we assembled a research team to gain a deeper understanding of the experience that one seasoned MUHC clinician described as "the darkest hour of his professional career." The goal of the qualitative study was to explore the second victim phenomenon across a range of professionals. The research team used the following definition to identify potential second victims for the project:

"Second victims are health care providers who are involved in an unanticipated adverse patient event, in a medical error and/or a patient related injury and become victimized in the sense that the provider is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base."(18)

We completed 31 qualitative interviews with individuals identified as potentially suffering from the second victim experience within a period of 4 years. Research participants included 10 physicians, 10 health professionals, and 11 registered nurses. Professional experience ranged between 6 months and 36 years (mean = 13.5 years). Time lapse since the unanticipated clinical event ranged from 3 weeks to 44 months (mean = 14 months). Incredibly, many of the research participants provided meticulously detailed accounts of their respective events. Some were able to cite the exact date of the event while others provided event-specific details such as the color of scrubs worn when the event occurred. One of the most striking findings was that every second victim participating in the project described their respective unanticipated clinical event as a life-altering experience that left a lasting impression on them. One clinician described his second victim experience as an "emotional tsunami," unlike anything he had ever experienced before in his professional career.

Numerous variables contributed to the severity of the second victim response. A patient that 'connected' the clinician to his/her own family (such as a patient with the same name, age, or physical characteristics as a loved one), the relationship between the patient and caregiver, length of professional relationships, cases that involved pediatric patients, and the clinician's past clinical experiences influenced the severity of the second victim's response to the safety event.

Although research participants developed individualized coping skills, they described a fairly predictable recovery trajectory. During iterative analyses, we identified six stages that described the second victim recovery process: (i) chaos and accident response, (ii) intrusive reflections, (iii) restoring personal integrity, (iv) enduring the inquisition, (v) obtaining emotional first aid, and (vi) moving on.(18) The sixth stage was unique in that it led to one of three potential outcomes: dropping out, surviving, or thriving. The Table illustrates the six-stage recovery trajectory as well as stage characteristics and recommended institutional interventional coping strategies. To validate these findings, we conducted focus groups with original research participants. Participants reviewed the proposed recovery trajectory and validated that they had indeed experienced the identified stages. The participants then offered their recommendations regarding desired or ideal institutional support for each stage.

Research participants provided many insights into the complex second victim phenomenon. Although each clinician's experience is unique, their evoked response story is somewhat predictable, which might lead one to believe that a stereotypical program of support would be effective. Yet individual clinicians have unique support needs, and our experience has taught us that no one intervention will meet everyone's support needs.

In addition, many second victims described a stigma they felt after they sought assistance; they often felt that others saw their efforts to seek help as a sign of professional/personal weakness and vulnerability. It is important to design an infrastructure with numerous support options to address these needs (such as employee assistance programs [EAPs], clergy, social workers, clinical psychologists, or counselors). In addition to offering a menu of support options, we have also come to believe that a robust second victim support infrastructure will include 24/7 availability with immediate access to support (19,20), leadership presence/support, and opportunities for individuals to contribute to organizational learning from the event as well as participate in any identified system redesign efforts.

How does this actually work in practice? Let's say a nurse on the evening shift harms a patient by administering the wrong medication. In a traditional health care setting, the department manager would be notified of the event and a report entered into the hospital's incident reporting system for review by risk management. The staff member is interviewed and investigation findings are considered. A root cause analysis (if indicated) is planned. However, in a health care system that focuses on addressing both patient incident investigations and the distinct needs of a second victim, real-time surveillance of all caregivers by individuals specifically educated on the second victim phenomenon occurs as the unanticipated clinical event unfolds. An emotional first aid rapid response team for the clinician is instantaneously deployed to address the needs of the second victim with immediate support and guidance.(21)

So, at our institution today, in the above medication error case, the house supervisor or potentially a unit colleague trained in second victim identification would proactively identify the staff member in need of support and immediately offer guidance. Members of University of Missouri Health Care System's second victim support team are purposefully embedded on every shift in high-risk clinical areas (such as intensive care units or operating rooms) as well as on high-risk clinical teams (such as rapid response teams, code blue teams, and palliative care teams). In addition, the house supervisors have been trained in identification of second victims and rapid referrals to peer supporters are made by activating a 24/7 pager that is available for clinicians regardless of job title. Our team's ultimate goal is to ensure that the clinician does not go home after an unanticipated clinical event to suffer alone. Clinicians who are severely traumatized and require the services of a professional counselor also benefit from a fast-track referral process to clinical health psychologists, counselors, clergy, social workers, or the EAP.

It is important to recognize that clinician support is a completely separate function from that of the event investigation. One person provides peer support while a different individual (either patient safety expert or risk manager) serves as the investigative lead for the investigation and review of the clinical event. We have found that initial support of the second victim—followed by the traditional event investigation—yields more efficient case exploration by the designated case investigator. If an RCA is indicated, our institution has opted to invite the second victim to participate in the case review to help address identified system issues and build action plans to prevent future incidents. In our experience, inclusion in these blame-free discussions helps promote clinician healing and recovery from the second victim experience. Participation in both the RCA meeting and second victim support is a voluntary process.

Awareness of the second victim phenomenon and proactive institutional response planning are critical steps in protecting and supporting future clinicians from the emotional trauma so often experienced by clinicians after unanticipated clinical events or medical errors.(22) When a serious event occurs, the health care system with a strong culture of safety immediately responds not only to support patients and family members, but also provides support to its clinicians. Doing this requires leadership engagement, preparedness, and a strong infrastructure for clinician support.(23)

Susan D. Scott, RN, MSNCoordinator, Patient Safety, University of Missouri Health Care Doctoral Student, University of Missouri–Columbia Sinclair School of Nursing

References

1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. National Academies Press; 2000. ISBN: 9780309068376.

2. Kumar S. Fatal Care: Survive in the U.S. Health System. Minneapolis, MN: IGI Press; 2008. ISBN: 9780977712113.

3. Hilfiker D. Facing our mistakes. N Engl J Med. 1984;310:118-122. [go to PubMed]

4. Levinson W, Dunn PM. A piece of mind. Coping with fallibility. JAMA. 1989:261;2252. [go to PubMed]

5. Hilfiker D. Healing the Wounds: A Physician Looks at his Work. New York, NY: Pantheon Books; 1985. ISBN: 978-0394559063.

6.The mistake I'll never forget. Nursing. 1990;20:50-51. [go to PubMed]

7. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320:726-727. [go to PubMed]

8. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:16;2089-2094. [go to PubMed]

9. Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med. 1992;7:424-431. [go to PubMed]

10. Wu AW, Folkman S, McPhee SJ, Lo B. How house officers cope with their mistakes. West J Med. 1993;159:565-569. [go to PubMed]

11. Newman M. The emotional impact of mistakes on family physicians. Arch Fam Med. 1996;5:71-75. [go to PubMed]

12. Wolf ZR, Serembus JF, Smetzer J, Cohen H, Cohen M. Responses and concerns of healthcare providers to medication errors. Clin Nurse Spec. 2000;14:278-287. [go to PubMed]

13. Engel KG, Rosenthal M, Sutcliffe KM. Residents' responses to medical error: coping, learning, and change. Acad Med. 2006;81:86-93. [go to PubMed]

14. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296:1071-1078. [go to PubMed]

15. White AA, Waterman A, McCotter P, Boyle D, Gallagher TH. Supporting health care workers after medical error: considerations for healthcare leaders. J Clin Outcomes Manage. 2008;15:240-247.

16. Denham CR. TRUST: The 5 rights of the second victim. J Patient Saf. 2007;3:107-119. [Available at]

17. Surveys on Patient Safety Culture. Rockville, MD: Agency for Healthcare Research and Quality; 2011. [Available at]

18. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall L. The natural history of recovery for the health care provider "second victim" after adverse patient events. Qual Saf Health Care. 2009;18:325-330.[go to PubMed]

19. Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deployment of a second victim rapid response system. Jt Comm J Qual Patient Saf. 2010;36:233-240. [go to PubMed]

20. Scott SD, Hirschinger LE, Cox KR. Sharing the load. Rescuing the healer after trauma. RN. 2008;71:38-40, 42-43. [go to PubMed]

21. Scott SD, Hirschinger LE, McCoig MM, Cox KR, Hahn-Cover K, Hall LW. The second victim. In: DeVita MA, Hillman K, Bellomo R, eds. Textbook of Rapid Response Systems. New York, NY: Springer; 2011:321-330. ISBN: 9780387928524.

22. Carr S. Disclosure and Apology: What's Missing? Chestnut Hill, MA: Medically Induced Trauma Support Services, Inc.; 2009.

23. Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events. Institute for Healthcare Improvement. Cambridge, MA: Institute for Healthcare improvement; 2010. [Available at]

Table

Table. Recovery Trajectory for Second Victims and Recommended Support Strategies. ("ForYOU Team" is a rapid response team that provides emotional assistance to clinicians following unexpected patient events).

(Go to table citation in the text)

Click to enlarge.