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The second victim of unanticipated adverse events

Published:September 14, 2022DOI:https://doi.org/10.1016/j.jtcvs.2022.09.010

      Key Words

      Figure thumbnail fx1
      Medical errors lead to many kinds of suffering (“Pain” by Antanas Zmuidzinavicius, 1876-1966).
      Cardiothoracic surgeons are at high risk for medical errors and becoming second victims; much can be done to mitigate suffering.
      See Commentary on page XXX.
      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.
      • Scott S.D.
      • Hirschinger L.E.
      • Cox K.R.
      • McCoig M.
      • Brandt J.
      • Hall L.W.
      The natural history of recovery for the healthcare provider “second victim” after adverse patient events.
      Medical errors are associated with costs that weigh most heavily on patients; mistakes made in health care settings are the third leading cause of death in this country.
      • Makary M.A.
      • Daniel M.
      Medical error-the third leading cause of death in the US.
      Patients and their families are not alone in bearing the burdens that stem from mistakes in diagnosis and treatment. Less appreciated is the suffering borne by the so-called second victim of unanticipated adverse events, who also endure consequences of the mistake: physicians, trainees, nurses, and other health care professionals (HCPs) who played a role in making the mistake.
      • Wu A.W.
      Medical error: the second victim.
      Although the idea of the second victim was proposed more than 2 decades ago and has been extensively studied since then, the phenomenon came into sharp focus recently because of the publicity surrounding the arrest, conviction, and sentencing of RaDonda Vaught, a nurse whose error, along with systemic flaws, caused a patient's death.
      • Skidmore S.
      • Ferrigno B.N.
      • Chen S.
      • Sade R.M.
      Keeping patients safe: criminal trials are not the way.
      Understanding medical errors and their effects on second victims can help the health care system to create optimal care for patients and a safe and productive environment for HCPs.

      Causes of Medical Errors

      The causes of medical errors are multifactorial. On an individual level, errors can be due to such factors as lack of knowledge or skills, fatigue due to long working hours, inadequate experience, faulty supervision, or case complexity.
      • Bari A.
      • Khan A.R.
      • Rathore A.W.
      Medical errors; causes, consequences, emotional response and resulting behavioral change.
      The recent pandemic has renewed focus on burnout in health care professionals, and its implications both for the healer and for patient care. Physicians who face burnout self-report more medical errors and patient safety incidents,
      • Shanafelt T.D.
      • Balch C.M.
      • Bechamps G.
      • Russell T.
      • Dyrbye L.
      • Satele D.
      • et al.
      Burnout and medical errors among American surgeons.
      and a correlation exists between higher rates of emotional exhaustion and the likelihood of committing a near-miss event or an error that resulted in patient harm.
      • Hewitt D.B.
      • Ellis R.J.
      • Chung J.W.
      • Moskowitz J.T.
      • Huang R.
      • Merkow R.P.
      • et al.
      Association of surgical resident wellness with medical errors and patient outcomes.
      On a broader scale, system failures usually play a major role in creating medical errors, as they did in the Vaught case.
      Teams of multidisciplinary professionals work together to provide patient care and several studies have shown that most errors are a result of broader systems flaws.
      • de Wit M.E.
      • Marks C.M.
      • Natterman J.P.
      • Wu A.W.
      Supporting second victims of patient safety events: shouldn't these communications be covered by legal privilege?.
      The most common source of errors is communication gaps or lack of thoroughness during resident physician and nursing handoffs of patient-related information.
      • Starmer A.J.
      • Spector N.D.
      • Srivastava R.
      • Srivastava R.
      • West D.C.
      • Rosenbluth G.
      • et al.
      Changes in medical errors after implementation of a handoff program.
      ,
      • Hada A.
      • Coyer F.
      Shift-to-shift nursing handover interventions associated with improved inpatient outcomes-Falls, pressure injuries and medication administration errors: an integrative review.
      Hierarchy within surgical groups may create an environment in which trainees feel uncomfortable questioning authority, even when they recognize impending errors. Many state practice laws reinforce allocation of individualized blame as opposed to policies aimed at improving the system.
      • Classen D.C.
      • Kilbridge P.M.
      The roles and responsibility of physicians to improve patient safety within health care delivery systems.

      Reducing Errors

      Systematic study of surgical mistakes and their effects on patient outcomes was introduced by Ernest Codman in the early 20th century in the form of his end result system.
      • Donabedian A.
      The end results of health care: Ernest Codman's contribution to quality assessment and beyond.
      One of Codman's major contributions was the creation of the regularly scheduled morbidity and mortality conference, a mainstay of surgical quality improvement for more than a century. The American College of Surgeons was created in 1913 and developed a system for evaluating hospital quality of outcomes, largely based on Codman's work. Collaboration among several organizations led to the creation of the Joint Commission on Accreditation of Hospitals in 1951, now simply the Joint Commission, which is responsible for ensuring safe and effective patient care through standardization of hospital quality. Other organizations providing oversight of hospital outcomes include the Centers for Medicare and Medicaid Services and The Leapfrog Group.
      The 1999 Institute of Medicine report To Err is Human brought into sharp focus the surprising frequency of errors in health care and the large number of deaths resulting from such mistakes.
      Institute of Medicine
      Committee on quality of health care in America.
      The report recommended the creation of safe reporting systems that protected confidentiality of those involved in the hope of creating a culture of safety in hospitals, focusing on system changes rather than placing blame on individuals. Hospitals have made some progress in developing cultures of safety, but errors continue to be a major problem; for example, a recent study found that 25% of Medicare patients experienced harm events in hospitals.
      Office of the Inspector General
      Adverse events in hospitals: a quarter of Medicare patients experienced harm in October 2018.

      Reporting Errors

      The only way that progress in reducing errors can occur is if they are reported, investigated, and acted upon, yet adverse outcomes are often not reported; the most frequent barriers to reporting are fear of the consequences for reporting, lack of feedback, and a culture of blame, shame, and punishment.
      • Aljabari S.
      • Kadhim Z.
      Common barriers to reporting medical errors.
      An investigation's root cause analysis can effectively identify the causes of adverse events of the error, but, although widely used, might not be effective in creating measures to prevent recurrences.
      • Martin-Delgado J.
      • Martínez-García A.
      • Aranaz J.M.
      • Valencia-Martín J.L.
      • Mira J.J.
      How much of root cause analysis translates into improved patient safety: a systematic review.
      An important component of the response should be for the surgeon to inform patients and their families that an error has occurred, what happened, that an investigation is being carried out, and that they will be informed of the resulting changes aimed at ensuring the mistake is not repeated. Hospital accreditation organizations and many state laws require that patients be informed about unanticipated outcomes in their care.
      • Leape L.L.
      Reporting of adverse events.
      Despite the mandate, unanticipated adverse outcomes, even when reported to hospital risk management officers, are often not reported to patients, mainly due to the fear of a lawsuit and damage to one's reputation. Yet informing patients that an error has occurred, even it did not harm them, is virtually universally believed to be an ethical duty, on grounds that a patient's autonomy, the right to self-determination, and the confidence and trust needed for a successful healing relationship requires full disclosure of all medical events.
      • Chamberlain C.J.
      • Koniaris L.G.
      • Wu A.W.
      • Pawlik T.M.
      Disclosure of “nonharmful” medical errors and other events: duty to disclose.
      Reporting errors to patients can have a beneficial effect: the physician can take ownership of the incident, mitigate guilt and shame, and rather than undermining can actually strengthen the patient's confidence and trust in the physician and in the health care system.

      The Second Victim

      Errors in health care are inevitable because HCPs are, like all human beings, imperfect. However, an aura of perfection in both the professionals and the care they provide has arisen as a result of the profusion of superb technologies and medications in recent decades. When mistakes occur, someone must have failed, on this view, so the proximate cause of the damage—the last person in the nexus of missteps that led to the error—becomes the immediate object of blame. Thus, a domino effect is set into motion, resulting in 4 groups of victims: the harmed patient and his or her family, the HCP who perpetrated the error, the hospital in which the mistake occurred, and future patients who will be harmed because of the inadequacies of corrective systems in most health care institutions.
      • Ozeke O.
      • Ozeke V.
      • Coskun O.
      • Budakoglu I.I.
      Second victims in health care: current perspectives.
      This sequence is well illustrated by the Vaught case, in which a series of systemic and personal errors led to the death of the patient, firing and criminal conviction of the last person in the series, nurse Vaught, who was saddled with all of the blame, a hit to the reputation of Vanderbilt hospital for evading its clear responsibility and role in the series of mistakes, and the future patients who could still be harmed by the hospital's uncorrected failings.
      • Skidmore S.
      • Ferrigno B.N.
      • Chen S.
      • Sade R.M.
      Keeping patients safe: criminal trials are not the way.
      When a medical error occurs, the prevalence of second victimhood—that is, the proportion of involved HCPs who experience a harmful personal effect—has been reported as around 30% to 40%.
      • Seys D.
      • Wu A.W.
      • Van Gerven E.
      • Vleugels A.
      • Euwema M.
      • Panella M.
      • et al.
      Health care professionals as second victims after adverse events: a systematic review.
      In 1 large series, 83.3% of physicians reported having been involved in 1 or more adverse events, and 76.5% believed the event affected their personal or professional lives.
      • Harrison R.
      • Lawton R.
      • Stewart K.
      Doctors' experiences of adverse events in secondary care: the professional and personal impact.
      The harms second victims experience range widely and may include anxiety, depression, fear, insomnia, guilt, shame, somatic symptoms, depression, and posttraumatic stress disorder.
      • Coughlan B.
      • Powell D.
      • Higgins M.F.
      The second victim: a review.
      Anger at oneself or as a reaction to blaming by others may predispose HCPs to substance abuse or other harmful behaviors, up to and including suicide.
      • Waterman A.D.
      • Garbutt J.
      • Hazel E.
      • Dunagan W.C.
      • Levinson W.
      • Fraser V.J.
      • et al.
      The emotional impact of medical errors on practicing physicians in the United States and Canada.
      ,
      • Christensen J.F.
      • Levinson W.
      • Dunn P.M.
      The heart of darkness: the impact of perceived mistakes on physicians.
      Women may be more prone than men to emotional sequelae of medical errors.
      • Waterman A.D.
      • Garbutt J.
      • Hazel E.
      • Dunagan W.C.
      • Levinson W.
      • Fraser V.J.
      • et al.
      The emotional impact of medical errors on practicing physicians in the United States and Canada.
      ,
      • Khansa I.
      • Pearson G.D.
      Coping and recovery in surgical residents after adverse events: the second victim phenomenon.
      Trainees are on the front lines of patient care, so are involved in many of the mistakes that inevitably occur. After involvement in a medical error, residents have reported lower quality of life, burnout, depersonalization, depression, and emotional exhaustion.
      • West C.P.
      • Huschka M.M.
      • Novotny P.J.
      • Sloan J.A.
      • Kolars J.C.
      • Havermann T.M.
      • et al.
      Association of perceived medical errors with resident distress and empathy.
      They may become insecure and fail to admit to mistakes in the future. Patient care may also suffer because of decreased empathy after an error occurs, due to detachment from patient care.
      Unexpected outcomes in surgical care are reported and openly discussed in surgical morbidity and mortality conferences that aim to reduce future complications by discussing what could have been done differently. These discussions address medical facts, and the emotional burden on those involved is rarely mentioned. Because they often focus on the negative, such conferences can add further harm to the second victim.
      • Wu A.W.
      • Steckelberg R.C.
      Medical error, incident investigation and the second victim: doing better but feeling worse?.
      Adding a section to those conferences that emphasizes positive outcomes can balance the negative tone of many discussions.

      Legal Implications

      Medical errors can be addressed in the legal system in 2 ways: most commonly as civil litigation in the form of medical malpractice lawsuits or, very rarely, as criminal prosecution—the Vaught case
      • Skidmore S.
      • Ferrigno B.N.
      • Chen S.
      • Sade R.M.
      Keeping patients safe: criminal trials are not the way.
      is a recent example. The goals of medical malpractice litigation are to deter unsafe medical practices, to compensate injured persons, and to exact corrective justice.
      • Mello M.M.
      • Frakes M.D.
      • Blumenkranz E.
      • Studdert D.M.
      Malpractice liability and health care quality: a review.
      However, it is doubtful that such litigation achieves any of these goals: harm to patients has not fallen, and compensation to patients is very uneven.
      • Mello M.M.
      • Frakes M.D.
      • Blumenkranz E.
      • Studdert D.M.
      Malpractice liability and health care quality: a review.
      The increasing complexity of medicine and intensified political and legal environment in recent years has resulted in an increase in medical malpractice claims within the court systems, estimated to cost more than $50 billion annually.
      • Kessler D.P.
      Evaluating the medical malpractice system and options for reform.
      Furthermore, medical specialties vary substantially in the likelihood of malpractice claims and the results of litigation.
      • Jena A.B.
      • Seabury S.
      • Lakdawalla D.
      • Chandra A.
      Malpractice risk according to physician specialty.
      Cardiothoracic surgeons and neurosurgeons face the highest risks for a lawsuit among all medical specialties: each year 19% of those surgeons have a malpractice claim against them, and by age 65 years, 99% have been sued.
      • Jena A.B.
      • Seabury S.
      • Lakdawalla D.
      • Chandra A.
      Malpractice risk according to physician specialty.
      Medical malpractice suits are time consuming and emotionally charged for both sides to the lawsuit, and are especially damaging to the accused, usually the attending physician or surgeon, even if the damaging act was performed by another HCP. The legal doctrine of respondeat superior holds attending physicians responsible for virtually any harm to their patients because they have ultimate responsibility for the patient's well-being. A lawsuit adds an additional layer of emotional, social, and physical damage to the turmoil the physician experiences after the original patient adverse event. More than 95% of defendants experience distress of some kind periodically throughout the legal proceedings, which often last for several years.
      • Charles S.C.
      Coping with a medical malpractice suit.
      Reactions include a sense of loss of control, feelings of failure and self-doubt, guilt, anxiety, depression, alcohol or drug misuse, physical symptoms, practice disruptions, and marital discord, among others. Several strategies for coping with the consequences of a lawsuit have been suggested. They include: seeking social support through discussion with a trusted colleague or friend; countering loss of control by participating in legal processes, selection of experts, and rebalancing personal and professional time; and changing the personal impact of the event by objective evaluation and maintaining belief in one's own competence.
      • Charles S.C.
      Coping with a medical malpractice suit.

      A Way Forward

      Much has been published about the need to promote and implement a just culture to create a safe environment in hospitals by addressing systemic issues that lead to errors while maintaining individual accountability.
      • Marks D.
      Patient safety and the just culture.
      ,
      Agency for Healthcare Research and Quality, Patient Safety Network
      Culture of safety.
      Such a culture of safety aims to reduce the risks of harm to the patient, the HCPs, the hospital, and future patients, yet little evidence exists to indicate that health care-related harms have diminished over the past 2 decades. Medical errors are inevitable, so it is essential to create a system in which HCPs are able to handle errors both personally and professionally. Surgical culture sees vulnerability as a personal flaw and focuses on practical and technical aspects of complications and the errors that lead to them; it does not encourage discussion of emotional and behavioral effects, so it facilitates repression, self-defense, and depersonalization.
      • Pinto A.
      • Faiz O.
      • Bicknell C.
      • Vincent C.
      Surgical complications and their implications for surgeons' well-being.
      ,
      • Bunni J.
      Complications—a surgeon's perspective and humanities' methods for personally dealing with them: the “4 R's”.
      To enable safe reporting of errors, institutions must protect and encourage the willingness of those involved in errors to ask questions, express concerns, and request help.
      While reduction of unexpected adverse events that affect patients remains of paramount importance, more can and should be done to mitigate the harmful consequences for the second victim. Understanding the usual trajectory toward recovery is helpful in determining what might be done. A study of second victims found a 6-stage pathway toward recovery
      • Scott S.D.
      • Hirschinger L.E.
      • Cox K.R.
      • McCoig M.
      • Brandt J.
      • Hall L.W.
      The natural history of recovery for the healthcare provider “second victim” after adverse patient events.
      (Table 1). The first 3 stages could occur sequentially or simultaneously. Stage 6 is critical because it determines the degree of success or failure of the HCP in dealing with the damaging effects of the error. Which pathway the victim chooses—dropping out, surviving, or thriving—depends in part the quality and amount of support that is made available to and accessed by the victim. So how can support for second victims be offered and utilization encouraged?
      Table 1The path to recovery of the second victim follows a predictable path, in 6 stages. The alternatives in Stage 6 determine the quality of the outcome (modified from reference 1)
      By permission, Lithuanian National Museum of Art
      Stage 1: Chaos and accident response
      • Error realized/event recognized
      • Tell someone, get help
      • Stabilize, treat patient
      Stage 2: Intrusive reflections
      • Haunted reenactment of event
      • Feelings of inadequacy
      Stage 3: Restoring personal integrity
      • Acceptance within work/social structure
      • Managing gossip/grapevine; fear is prevalent
      Stage 4: Enduring the inquisition
      • Realization of level of seriousness
      • Reiterate case scenario
      • Interact with many other event participants
      • Event disclosure to patient/family
      • Physical and psychosocial symptoms
      Stage 5: Obtaining emotional support
      • Seek personal/professional support
      • Getting/receiving help/support
      • Litigation concerns emerge
      Stage 6: Moving on (one of three trajectories)
      • Dropping out
        • Transfer to a different unit or facility
        • Consider quitting
        • Feelings of inadequacy
      • Surviving
        • Coping, but still have intrusive thoughts
        • Persistent sadness, trying to learn from event
      • Thriving
        • Maintain personal/professional life balance
        • Gain insight/perspective
        • Does not base practice/work on 1 event
        • Advocates for patient safety initiatives
      Table 2Interventions are available to mitigate the risk to second victims and to optimize their recovery, ranging from culture change to personal support
      • Waterman A.D.
      • Garbutt J.
      • Hazel E.
      • Dunagan W.C.
      • Levinson W.
      • Fraser V.J.
      • et al.
      The emotional impact of medical errors on practicing physicians in the United States and Canada.
      ,
      • Lane M.A.
      • Newman B.M.
      • Taylor M.Z.
      • O'Neill M.
      • Ghetti C.
      • Woltman R.M.
      • et al.
      Supporting clinicians after adverse events: development of a clinician peer support program.
      • El Hechi M.W.
      • Bohnen J.D.
      • Westfal M.
      • Han K.
      • Cauley C.
      • Wright C.
      • et al.
      Design and impact of a novel surgery-specific second victim peer support program.
      • Shapiro J.
      • Galowitz P.
      Peer support for clinicians: a programmatic approach.
      • Scott S.D.
      • McCoig M.M.
      Care at the point of impact: insights into the second-victim experience.
      Implement strategies that support a culture of safety
       Just CultureAccountability structure recognizes human behaviors that result in adverse events—errors, at-risk, or reckless—and ensures a system-based approach to continuous improvement
       Reporting CultureEnsures reporting is perceived as safe, easy, and effective
       Learning CultureEncourages continuous improvements and learning from mistakes
      Understand and recognize the 6-stage-pathway toward recoveryAims to encourage Stage 6: Thriving
      Implement formal support systems for second victims
      • Structured debriefing after events
      • Peer support program
      • Stress management program
      Both informal and formal support systems can be helpful throughout the victim's recovery stages. When an unexpected adverse event occurs, colleagues can offer support by talking with the victim, encouraging a description of what happened, and accepting the description without minimizing the importance of the mistake. Asking about the emotional impact of the mistake and how the colleague is coping can help to begin the healing process.
      • Wu A.W.
      Medical error: the second victim.
      Institutional programs can also be helpful in aiding recovery. Emotional and factual debriefing sessions should part of adverse event management. Formal systems aimed at managing the stresses associated with medical errors in health care environments are available, including peer support and stress management programs (Table 2).
      • Lane M.A.
      • Newman B.M.
      • Taylor M.Z.
      • O'Neill M.
      • Ghetti C.
      • Woltman R.M.
      • et al.
      Supporting clinicians after adverse events: development of a clinician peer support program.
      • El Hechi M.W.
      • Bohnen J.D.
      • Westfal M.
      • Han K.
      • Cauley C.
      • Wright C.
      • et al.
      Design and impact of a novel surgery-specific second victim peer support program.
      • Shapiro J.
      • Galowitz P.
      Peer support for clinicians: a programmatic approach.
      • Scott S.D.
      • McCoig M.M.
      Care at the point of impact: insights into the second-victim experience.

      Conclusions

      Human beings are fallible, so unexpected adverse events—medical errors—are inevitable. Long-standing efforts to reduce patient harms have met with modest success, but far too many mistakes still occur, leading to dire outcomes, first, for harmed patients, but also for second, third, and fourth victims: HCPs, health care institutions, and future patients. Emotional, social, and other harms experienced by second victims have been described and analyzed in many scholarly studies over the past 2 decades, and approaches to mitigate the harms have been developed and prescribed; yet most health care organizations still have no formal system for supporting the second victim, and when such systems are available, they are underutilized by those in need.
      Unrepaired systemic flaws and unsupported HCPs foretell continuing damage to future patients. Like injured patients, HCPs can be harmed, sometimes severely so, by the fallout from medical errors. Therefore, developing and maintaining a culture of safety in hospitals is critically important. A key part of such a culture is a system of support for HCPs. Such systems are available. We should use them.

      Conflict of Interest Statement

      The authors reported no conflicts of interest.
      The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
      The authors thank Danielle B. Scheurer, MD, for her review of the manuscript and valuable suggestions.

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