Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations

Mira, José Joaquín; Lorenzo, Susana; Carrillo, Irene; Ferrús, Lena; Silvestre, Carmen; Astier, P.; Iglesias-Alonso, F.; Maderuelo, José A.; Pérez-Pérez, Pastora; Torijano, Maria Luisa; Zavala, Elena; Scott, Susan D.; Victims, Third

doi:10.1093/intqhc/mzx056

Cited by 58 publications

(68 citation statements)

References 77 publications

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“…It has been reported that a second victim may be affected to varying degrees in terms of physical health, psychological health, professional efficacy and other aspects and that PSIs can even reoccur (Cabilan & Kynoch, 2017; Mira, Carrillo, et al, 2017; Mira, Lorenzo, et al, 2017; Pratt & Jachna, 2015), which deserves the attention of managers in the medical field. Scott (Scott et al, 2009) believes a post‐event trajectory is predictable, and the following six stages are identified: chaos and accident response, intrusive reflections, restoring personal integrity, enduring the inquisition, obtaining emotional first aid and moving on.…”

Section: Introductionmentioning

confidence: 99%

“…Scott (Scott et al, 2009) believes a post‐event trajectory is predictable, and the following six stages are identified: chaos and accident response, intrusive reflections, restoring personal integrity, enduring the inquisition, obtaining emotional first aid and moving on. In addition, assistance for second victims is of great significance, and discussing the event with colleagues, feeling respect and empathy from others and being supported by institution are helpful in coping with the emotional impact (Dukhanin et al, 2018; Edrees et al, 2016; Mira, Carrillo, et al, 2017; Mira, Lorenzo, et al, 2017). However, the literature has also emphasized that thus far, such support is limited in health systems due to the failure to identify potential second victims, insufficient support interventions and the lack of a patient safety culture (Quillivan et al, 2016; Stewart et al, 2015; Tsao & Browne, 2015; Zhang et al, 2019).…”

Section: Introductionmentioning

confidence: 99%

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Experiences and responses of nursing students as second victims of patient safety incidents in a clinical setting: A mixed‐methods study

et al. 2020

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Aim To investigate the degree of second victim syndrome among nursing students in clinical practice and determine the rehabilitation process. Background Empirical evidence suggests that health care providers who are considered second victims suffer from various difficulties. Nursing students in a clinical setting could be potential second victims, but few studies have quantitatively investigated the experiences and explored their response processes. Methods A mixed‐methods design was used. A questionnaire was sent to nursing students via a link to an electronic survey, and a semi‐structured interview was conducted to explore their response process as second victims. Results The quantitative results showed that nursing students in the clinical setting suffered second victim‐related distress and that the most significant influences were psychological distress and professional efficacy. Four stages of rehabilitation experiences emerged from the qualitative data. Conclusion Being a second victim for nursing students in a clinical setting is psychological suffering, and although they can be expected to recover, an impact on professional efficacy is inevitable. Implications for Nursing Management Nursing managers must be aware that nursing students in a clinical setting might experience difficult situations after patient safety incidents and that developing appropriate programmes to support at‐risk students is important.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Experiences and responses of nursing students as second victims of patient safety incidents in a clinical setting: A mixed‐methods study

et al. 2020

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“…These data contrast with those found in other countries that have made a greater effort to replace the punitive culture after the error. For example, the number of hospitals that do have support programs for second victims is notably higher in the USA [24] (74%) and the Netherlands [6] (30%). However, they tend to coincide with the results of the study carried out in Spain in which around 70% of patients who suffered an AE did not receive adequate information about the incident or to obtain fair compensation.…”

Section: Discussionmentioning

confidence: 99%

“…It is more difficult for patients suffering from AEs to receive information about what happened and for their right to fair compensation to be respected. On the other hand, professionals involved in safety incidents suffered by patients (and their families) often find it difficult to discuss what happened with their colleagues and middle-managers, question their own professional capacity and ultimately make wrong decisions more easily [6].…”

Section: Aftermatch Of Safety Eventsmentioning

confidence: 99%

What Ibero-American hospitals do when things go wrong? A cross-sectional international study

Mira

Carrillo

García-Elorrio

et al. 2020

International Journal for Quality in Health Care

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Objective To know what hospital managers and safety leaders in Ibero-American countries are doing to respond effectively to the occurrence of adverse events (AEs) with serious consequences for patients. Design Cross-sectional international study. Setting Public and private hospitals in Ibero-American countries (Argentina, Brazil, Chile, Colombia, Mexico, Peru, Portugal and Spain). Participants A convenience sample of hospital managers and safety leaders from eight Ibero-American countries. A minimum of 25 managers/leaders from each country were surveyed. Interventions A selection of 37 actions for the effective management of AEs was explored. These were related to the safety culture, existence of a crisis plan, communication and transparency processes with the patients and their families, attention to second victims and institutional communication. Main Outcome Measure Degree of implementation of the actions studied. Results A total of 190 managers/leaders from 126 (66.3%) public hospitals and 64 (33.7%) private hospitals participated. Reporting systems, in-depth analysis of incidents and non-punitive approaches were the most implemented interventions, while patient information and care for second victims after an AE were the least frequent interventions. Conclusions The majority of these hospitals have not protocolized how to act after an AE. For this reason, it is urgent to develop and apply a strategic action plan to respond to this imperative safety challenge. This is the first study to identify areas of work and future research questions in Ibero-American countries.

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“…The risk factors for occupational injury can be attributed to an interaction between characteristics of the worker and the patient, and the workplace [9,10]. Adverse events may affect not only HCWs but also patients, and in addition may have a negative impact on relatives and health care organizations, all considered as a signi cant problem [11,12]. Approximately 10-15% of patients are affected by an adverse event during their hospital stay, and a substantial part of these events are considered preventable [13,14].…”

Section: Introductionmentioning

confidence: 99%

Health Care Workers’ Experiences of Workplace Incidents that Posed a Risk of Patient and Worker Injury: A Critical Incident Technique Analysis

Strid

Wåhlin

Ros

et al. 2020

Preprint

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Background Health care workers (HCWs) are at high risk of occupational injuries and approximately 10-15% of patients are affected by an adverse event during their hospital stay. There is scarce scientific literature about how HCWs manage these risks in practice and what support they need. This knowledge is needed to improve safety for patients and HCWs. This study explores HCWs’ experiences of workplace incidents that led to injury or posed a risk of patient and worker injury, with focus on HCWs’ actions and emotions.Methods This study employed a qualitative design using the critical incident technique. Semi-structured individual interviews were held with 34 HCWs from three regions in Sweden. Data were analysed using inductive category development. Results Altogether 71 workplace incidents were reported. The analysis of two dimensions – actions HCWs take and emotions they feel when a workplace incident occurs – yielded two main areas each: HCWs’ actions, actions by the team and managers, anxiety during the incident, and persistent distress after the incident. Health care workers risked their own safety and health to provide patient safety. Teamwork and trustful relationships were critical for patient and worker safety. Support and validation from colleagues and managers were important for closure; unsatisfactory manager response and insufficient opportunities to debrief the incident could lead to persistent negative emotions. Participants described insecurity and fear, sadness over being injured at work, and shame and self-regret when the patient or themselves were injured. When the workplace had not taken the expected action, they felt anger and resignation, often turning into long-term distress. Conclusions Work situations leading to injury or risk of patient and worker injury are emotionally distressing for HCWs. Team interplay may facilitate safe and dynamic practices and help HCWs overcome negative emotions. Organizational support is imperative for individual closure. For safety in health care, employers need to develop strategies for active management of risks, avoiding injuries and providing support after an injury.

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Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations

Cited by 58 publications

References 77 publications

Experiences and responses of nursing students as second victims of patient safety incidents in a clinical setting: A mixed‐methods study

Experiences and responses of nursing students as second victims of patient safety incidents in a clinical setting: A mixed‐methods study

What Ibero-American hospitals do when things go wrong? A cross-sectional international study

Health Care Workers’ Experiences of Workplace Incidents that Posed a Risk of Patient and Worker Injury: A Critical Incident Technique Analysis

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