Second Victim

Overview of Issue

Healthcare providers involved in incidents involving serious injury or death to a patient may suffer emotional trauma, and are at high risk for burnout, self-harm and may leave the profession. The term “second victim” was coined to draw attention to this problem and highlight the need for better support for healthcare providers in the immediate aftermath of patient safety incidents.

Key Points

• Healthcare leaders should ensure support is provided for healthcare providers involved in patient safety incidents.

Things to Consider

Work-Related Outcomes

• The emotional trauma experienced by second victims includes guilt, loss of confidence, and shame; feelings can last for varying lengths of time.
• Healthcare providers involved in patient safety incidents may be able to function at work, opt out of a perceived high risk area of care, require time off, or quit the profession. Organizational support can impact which outcome a second victim experiences.
• Implementation of second victim supports will have a positive influence on patient safety culture.
• Stress associated with patient safety incidents begins long before legal action is commenced (if it is) and is often associated with incidents that do not become lawsuits. Research indicates that communication with a patient and family after a patient safety incident, with an apology as appropriate, does not increase the likelihood of a lawsuit (Mello et al., 2017).

Stages of Recovery

• Six stages of recovery (Scott & McCaig, 2016) have been identified for second victims (stages may be experienced simultaneously):
  • Chaos and accident response – state of shock, distracted, and possible need for others to take over;
  • Intrusive reflections – feelings of inadequacy, self-doubt, and loss of confidence;
  • Restoring personal integrity – support is sought while there is worry of how others will react;
  • Enduring the inquisition – time of organizational investigation, fears about employment and litigation;
  • Obtaining emotional first aid – desire for guidance yet may be unclear about who to trust and turn to for support; and
  • Moving on – could take the form of dropping out, surviving, or thriving.

Tips to ensure support

• Leaders should establish an organizational expectation that “anything less than a supportive response is unacceptable” (Wu & Steckelberg, 2012). This support could include:
  • Implementing a ‘just culture’ policy and ensuring an environment where healthcare providers are comfortable speaking up;
  • Expressing empathy and delivering emotional “first-aid” (e.g. I’m sorry this happened to you, we’ll figure this out together);
  • Ensuring access to counselling (e.g. employee assistance program or trained peer supports);
  • Ensuring access to formal interventions to address emotional or physical deterioration;
  • Identifying and addressing unsupportive or critical colleagues;
  • Coaching on how to interact with and disclose the incident to the patient and family;
  • Providing information on next steps and how staff will be able to contribute to the incident analysis;
  • Ensuring respectful interactions and discussions with staff in the course of incident analysis;
  • Providing information on potential legal processes that might surround the incident in collaboration with the insurance adjuster and legal counsel;
  • Providing support to resume/continue practice;
  • Undertaking an assessment to understand the current climate with respect to supporting second victims;
  • Creating awareness of the realities that second victims experience; and
  • Including “just culture” policy in new staff orientation, annual education, and training.

Types of Support to Offer Second Victims

• Unit or department based support systems – support provided by healthcare providers who have received basic response training and can relieve the second victim of their duties. The majority of second victims will have their needs met with this type of support.
• Peer support programs – trained healthcare providers offer immediate assistance (e.g. active listening, assisting with identification of coping strategies) to second victims in person or by phone. Peer support programs have been shown to be cost effective in the hospital setting by lowering turnover and reducing net monetary losses.
• External referral – providing access to an employee assistance program or professional counseling.

Note: Caution should be taken in discussing details of incidents as this may be discoverable.

REFERENCES

• HIROC. (2015). Critical incidents & multi-patient events. Risk Resource Guide.
• AHRQ PS Net. (2016). Second victims: Support for clinicians involved in errors and adverse events. Patient Safety Primer.
• Burlison J, Quillivan R, Scott S, et al. (2016). The effects of the second victim phenomenon on work-related outcomes: Connecting self-reported caregiver distress to turnover intentions and absenteeism. J Patient Saf.
• de Wit M, Marks C, Natterman J, et al. (2013). Supporting second victims of patient safety events: Shouldn’t these communications be covered by legal privilege? J Law Med Ethics. 41(4):852-858.
• Mello M, Kachalia A, Roche S, et al. (2017). Outcomes in two Massachusetts hospital systems give reason for optimism about communication-and-resolution programs. Health Aff. 36(10):1795-1803.
• Moran D, Wu A, Connors C, et al. (2017). Cost-benefit analysis of a support program for nursing staff. J Patient Saf.
• Scott S. (2015). Second victim support: Implications for patient safety attitudes and perceptions. Patient Safety & Quality Healthcare. 12(5):26-31.
• Scott S, McCaig M. (2016). Care at the point of impact: Insights into the second-victim experience. J Healthc Risk Manage. 35(4): 6-13.
• Wu A, Steckelberg R. (2012). Medical error, incident investigation and the second victim: Doing better but feeling worse. BMJ Qual Saf. 21(4):267-70