PDF
ePub
Citation
Print
Abstract
Purpose:
The purpose of this study was to identify the current state of research on healthcare professionals who make medical errors, who are known as “second victims”, and support systems for them. Methods: An extensive search was conducted in electronic databases, Google, and websites related to patient safety using search terms such as “second victims”, “medical errors”, “adverse events”, and “sentinel events”. Results: Research to date in Korea has rarely focused on healthcare professionals’ experiences after making medical errors. Abroad, there are comprehensive and systematic reviews of the impact of medical errors on healthcare professionals, their coping responses, and support systems for these second victims. Additionally, several institutes related to patient safety provide official guidelines and accessible support systems to support second victims in the aftermath of medical errors, especially serious adverse events. Conclusion: The impact of medical errors on healthcare professionals is profound and complex. Although systematic support systems for second victims are imperative, this has been overlooked in Korea. Thus, more research about the experiences of healthcare professionals after medical errors needs to be conducted prior to developing support systems or programs. Additionally, further efforts are required to raise awareness of the necessity of supporting healthcare professionals in healthcare systems.
REFERENCES
1.Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academies Press;2000.
2.Denham CR. Trust: the 5 rights of the second victim. J Patient Saf. 2007. 3(2):107–19. http://dx.doi.org/10.1097/01.jps.0000236917.02321.fd.
3.Wu AW. Medical error: the second victim. BMJ. 2000. 320(7237):726–7.
4.Scott SD., Hirschinger LE., Cox KR., McCoig M., Brandt J., Hall LW. The natural history of recovery for the healthcare provider "second victim" after adverse patient events. Qual Saf Health Care. 2009. 18(5):325–30. http://dx.doi.org/doi:10.1136/qshc.2009.032870.
5.Seys D., Wu AW., Gerven EV., Vleugels A., Euwema M., Panella M, et al. Health care professionals as second victims after adverse events: a systematic review. Eval Health Prof. 2013. 36(2):135–62. http://dx.doi.org/10.1177/0163278712458918.
6.Edrees HH., Paine LA., Feroli ER., Wu AW. Health care workers as second victims of medical errors. Pol Arch Med Wewn. 2011. 121(4):101–8.
7.Cho HA., Shin H. A systematic review of published studies on patient safety in Korea. J Korean Acad Dent Adm. 2014. 2(1):61–82.
8.Noh DB., Kim SA., Kim SH. Moral distress, moral sensitivity and ethical climate of nurses working in psychiatric wards. J Korean Acad Psychiatr Ment Health Nurs. 2013. 22(4):307–19.
9.Kim HR., Ahn SH. Moral sensitivity and moral distress among Korean hospital nurses. Korean J Med Ethics. 2010. 13(4):321–36.
10.Yoo MS. A study on the degree of moral distress of nurses in a city. J Korean Acad Nurs Admin. 2006. 12(1):131–9.
11.Han SS. The moral distress experienced by hospital nurses. J Korea Bioeth Assoc. 2005. 12:31–47.
12.Cho HN., An M., So HS. Differences of turnover intention by moral distress of nurses. J Korea Contents Assoc. 2015. 15(5):403–13.
13.Lee EK., Jung CH., Jeon HJ. Experiences of nurses in medication errors. Qual Res. 2010. 12:94–105.
14.O'Connor E., Coates HM., Yardley IE., Wu AW. Disclosure of patient safety incidents: a comprehensive review. Int J Qual Health Care. 2010. 22(5):371–9. http://dx.doi.org/10.1093/intqhc/mzq042.
15.Sirriyeh R., Lawton R., Gardner P., Armitage G. Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professio-nals' psychological well-being. Qual Saf Health Care. 2010. 19(6):): e43.http://dx.doi.org/10.1136/qshc.2009.035253.
16.Lewis EJ., Baernholdt M., Hamric AB. Nurses' experience of medical errors: an integrative literature review. J Nurs Care Qual. 2013. 28(2):153–61. http://dx.doi.org/10.1097/NCQ.0b013e31827e05d1.
17.Seys D., Scott S., Wu AW., Gerven EV., Vleugels A., Euwema M, et al. Supporting involved health care professionals (second victims) following an adverse health event: a literature review. Int J Nurs Stud. 2013. 50(5):678–87. http://dx.doi.org/10.1016/j.ijnurstu.2012.07.006.
18.Conway J., Federico F., Stewart K., Campbell M. Respectful management of serious clinical adverse events: IHI innovation series white paper. 2nd ed.Cambridge: Institute for Healthcare Improvement;2011.
19.Disclosure Working Group. Canadian disclosure guidelines: being open with patients and families. Edmonton: Canadian Patient Safety Institute;2011.
20.Tysall A., Duffy A. Staff support: caring for the "second victims" of an adverse event. In: Open disclosure: national guidelines communicating with service users and their families following adverse events in healthcare. Ireland: Health Service Executive and State Claims Agency;2013. p. 15–25.
21.Australian Commission on Safety and Quality in Health Care. Staff considerations. In: Australian open disclosure framework. Sydney: ACSQHC;2013. p. 32–4.
22.Clark C. Medical error ‘second victims' get some help, finally [Internet]. Danvers: Health Leaders Media; [updated 2013 Jan 17]. Available from:. http://www.healthleadersmedia.com/content/QUA-288425/Medical-Error-Second-Victims-Get-Some-Help-Finally##.
23.Scott SD., Hirschinger LE., Cox KR., McCoig M., Kristin HC., Epperly KM. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010. 36(5):233–40.
24.Mitss.org [Internet]. Brookline/Boston: Medically Induced Trauma Support Services; [updated. 2009. cited 2016 Feb 1]. Available from:. http://www.mitss.org/aboutus_home.html.
25.Edelson M. Safety first. Hopkins Med [Internet]. 2013. Feb 1. Available from:. http://www.hopkinsmedicine.org/news/publications/hopkins_medicine_magazine/archives/winter_2013/safety_first.
26.Canadian Patient Safety Institute. Second victims: a landmark national conversation on providing timely psychological first aid. Can Patient Saf Inst News [Internet]. 2015. May 21. Available from:. http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/pages/second-victims-a-landmark-national-conversation-on-providing-timely-psychological-first-aid.aspx.
Table 1.
Summary of Included Systematic Review
| Categories | Sirriyeh el al. (2010) | Seys el al. (2013) | Seys el al. (2013) | Lewis et al. (2013) | Total n (%) |
|---|---|---|---|---|---|
| Goal | Identify impact of being involved in a medical error on the health professional, copping strategies in the short and longer term, and factors that influence the immediate response to error and/or the way in which individuals cope | Identify supportive interventional strategies for second victims | Review definitions of second victims, and prevalence of second victims, impact of the medical error/adverse event on the second victim, and individual coping strategies used by second victims | Review the effect of medical errors on nurse | ㅡ |
| Searching strategy | 1. Database searching | 1. Database searching | 1. Database searching | 1. Database searching | ㅡ |
| - WebofScience | - MEDLINE | - MEDLINE | - MEDLINE | ||
| - Medline | - EMBASE | - EMBASE | - CINAHL | ||
| - PsychInfo | - CINAHL | - CINAHL | - CochraneLibrary | ||
| - ScienceDirect, | 2. Manual search of reference lists | 2. Manual review of reference lists from relevant articles | 2. Manual search of reference lists | ||
| - The CochraneLibrary | |||||
| - Embase | 3. External review by three experts | ||||
| 2. Manual search of reference lists | 3. Review by three experts | ||||
| 3. Assessment of study quality | |||||
| Major search terms | Coping with/respond to/attitude towards/ commit/perception of committing/making/ recover from making | Psychology/emotions/ feelings/burnout/ depression/empathy /attitude of health personnel/burnout, professional [MeSH]/ depressive disorder [MeSH]/empathy [MeSH] | Psychology/emotions/ feelings/burnout/ depression/empathy / attitude of health personnel/burnout, professional [MeSH]/ depressive disorder [MeSH]/empathy [MeSH] | Nurse/nurses/ nursing | ㅡ |
| Coping/response/ attitude/commit/ perception/making/ recover | |||||
| - Medical error | |||||
| - Medical mistake | |||||
| - Medical mishap | - Medical error | ||||
| - Medical blunder | - Mistake | ||||
| - Medical adverse event | - Second victim | - Second victim | - Mishap | ||
| - Medical incident | - Medical error | - Medical error | - Blunder | ||
| - Medical error | - Medical error | - Adverse event | |||
| [MeSH] | [MeSH] | - Incident | |||
| - Adverse event | - Adverse event | ||||
| Inclusion criteria |
Published between 1980 and 2009 English language peer-reviewed journals |
Published until september 2010 Englishlanguage | Published through September 2010 English language |
Published between 1980 and December 2011 English language Peer-reviewed journals |
ㅡ |
| Studies that | Studies that | ||||
| - Used the error fit the Reason's definition | - Provided a definition of second victim in health care settings. | ||||
| - Focused on health professionals and trainees | - Assessed prevalence of medical errors/adverse events on health care providers. | ||||
| - Focused on the psychological or emotional outcomes of medical errors for health professionals | - Reproduced the impact of a medical error/adverse event on the health care provider. | ||||
| Exclusion criteria | Not suggested | Conference reports newspaper stories personal stories of health care professionals in a scientific journal | Not published in English, conference reports, newspaper stories, and personal stories of health care professionals in a scientific journal | Not suggested | ㅡ |
| Number of articles reviewed by target population | 24 | 31 | 41 | 21 | 117 |
| Doctors | 19 | 14 | 20 | 53 (43.1) | |
| Medical students | 3 | 2 | 4 | 9 (7.3) | |
| Medical educator | 1 | 2 | 1 | 4 (3.3) | |
| Nurse | 6 | 8 | 10 | 21 | 45 (36.6) |
| National experts | 1 | 1 | 2 (1.6) | ||
| Other health professionals | 2 | 1 | 2 | 5 (4.1) | |
| Patients | 1 | 1 | 1 | 3 (2.4) | |
| Not specified | 2 | 2 (1.6) | |||
| Type of study/Design† | |||||
| Research article | |||||
| Quantative | 10 | 8 | 12 | 1 | 31 (26.5) |
| Qualitative | 11 1 | 12 1 | 15 1 | 13 1 | 51 (43.6) 4 (3.4) |
| Mixed method | 1 | 1 | 1 | 1 4 | 4 (3.4) 4 (3.4) |
| Correlational | 4 1 | 4 (3.4) 1 (0.9) | |||
| Descriptive | 1 | 1 (0.9) | |||
| Comparison | 2 | 1 1 | 1 (0.9) 3 (2.6) | ||
| Prospective cohort | 2 | 1 2 | 3 (2.6) 2 (1.7) | ||
| 3~year longitudinal | 2 | 2 (1.7) | |||
| Prospective 3~year longitudinal | |||||
| Non research article‡ | 10 | 9 | 19 (16.2) | ||
| Setting | Primary, secondary, tertiary and community care settings | ||||
XML Download