- Email: [email protected]
The Second Victim: a Review
European Journal of Obstetrics & Gynecology and Reproductive Biology 213 (2017) 11–16
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Review article
The Second Victim: a Review B. Coughlana , D. Powellb,* , M.F. Higginsc,* a
UCD Midwifery, School of Medicine, University College Dubli, Republic of Ireland Department of Risk Management, Connolly Hospital, Dublin c Perinatal Research Center, UCD Obstetrics and Gynaecology, School of Medicine, National Maternity Hospital, University College Dublin, Republic of Ireland b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 16 January 2017 Received in revised form 7 March 2017 Accepted 1 April 2017
Amongst the lay and media population there is a perception that pregnancy, labour and delivery is always physiological, morbidity and mortality should be “never events” and that error is the only cause of adverse events. Those working in maternity care know that it is an imperfect art, where adverse outcomes and errors will occur. When errors do occur, there is a domino effect with three groups being involved the patient (first victim), the staff (second victims) and the organization (third victims). If the perceived expectation of patients on all clinicians is that of perfection, then clinicians may suffer the consequences of adverse outcomes in isolation and silence. More recently identification and discussion on the phenomenon of the second victim has become a popular research topic. This review aimed to study not only the phenomenon of second victim in general medical care but to also concentrate on maternity care where the expectation of perfection may be argued to be greater. Risk factors, prevalence and effect of second victims were identified from a thorough search of the literature on the topic. The review focuses on the recent research of the effect on maternity staff of adverse outcomes and discusses topical issues of resilience, disclosure, support systems as well as Learning from Excellence. It is now well documented that when staff members are supported in their disclosure of errors this domino effect is less traumatic. It is the responsibility of everyone working in healthcare to support all the victims of an error, as an ethical duty and to have a supportive culture of disclosure. In addition, balance can be provided by developing a culture of learning from excellence as well as from errors. © 2017 Elsevier B.V. All rights reserved.
Keywords: Second Victim Domino Effect Maternity
Contents Debriefing . . . . . . . . . . . Coping and Recovery . . Experience of reporting Resilience . . . . . . . . . . . System support . . . . . . . Providing a balance . . . Conclusion . . . . . . . . . . ACKNOWLEDGEMENTS References . . . . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
Medicine is an imperfect art. Sixteen years ago it was estimated that medical errors caused up to 98,000 deaths per year in the
* Corresponding author. Mary Higgins, UCD Obstetrics and Gynaecology, 65–66 Lower Mount Street, Dublin 2, Republic of Ireland. E-mail address: [email protected] (B. Coughlan). http://dx.doi.org/10.1016/j.ejogrb.2017.04.002 0301-2115/© 2017 Elsevier B.V. All rights reserved.
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
13 14 14 14 15 15 15 15 15
United States [1], at the time considered the fourth most common cause of death. More recently it has been suggested that this may be an underestimation, as previous studies rely on errors extractable from health records, include only inpatients, or, in the United States, rely on cause of death based on International Classification of Disease (ICD) codes that do not capture human or system factors [2]. The current best estimation is that medical error
12
B. Coughlan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 213 (2017) 11–16
is the now the third biggest cause of death in the US [2], with a mean rate of death from medical error of 251,454/year. Maternity care, as a discipline within medicine, is also an imperfect art. Though the rate of mortality in maternity care is low, some maternal deaths in the United Kingdom and Ireland have been associated with sub-standard care [3] 3. With regard to morbidity, one in twelve labours can result in adverse outcome to mother or baby [4] 4. Contributory factors including patient demographics, work overload, task saturation, distractions, poor teamwork, sub-optimal communication, mental models, fixation and lack of leadership, as well as situational awareness may not have always caused the adverse outcome but may contribute to the response to the outcome and may result in an implication of medical error [5] 5. This is further confounded by a widespread perception amongst the lay population and the media that pregnancy, labour and delivery are always physiological, deaths should be “never events” and that error is the only cause of adverse events in maternity care [7]. There is a perception that the general public have an “expectation that childbirth was a jubilant event and to suggest any possible harm to the mother was met with incredulity” [8]. Healthcare professionals are conditioned to function at a high level of proficiency with the emphasis on perfection [9] 9 Society too tends to expect of clinicians an image of perfection, which can lead to the clinician having to suffer the consequences of a mistake in silence and isolation [10]. In the same year as Kohn estimated the rate of medical error, Albert Wu coined the term “second victim”. Wu described medicine as an imperfect science, as “many errors are built into existing routines and devices, setting up the unwitting physician and patient for disaster” [11], despite the expectation of near perfection by patients, clinicians and administrators. While acknowledging the crucial importance that the patient must always come first “although patients are the first and obvious victims of medical mistakes”- he also acknowledged the effect of error on clinicians, who “are wounded by the same errors: they are the second victims”. The definition was further refined nine years later, with the second victim being described as ‘A health care provider involved in an unanticipated adverse patient event, medical error, and/or a patient related–injury who become victimized in the sense that the provider is traumatized by the event. Frequently second victims feel personally responsible for the unexpected patient outcomes and feel as though they have failed their patient, second guessing their clinical skills and knowledge base’ [12]. An “intolerable paradox” has been described of the clinician who makes a mistake -“we see the horror of our own mistakes, yet, we are given no permission to deal with their enormous emotional impact . . . . the medical profession simply has no place for its mistakes” [13]. The effect of an error can have an enormous emotional, professional and personal drain [11], whether this involves personal or local review, litigation, coroners’ inquest, court, or
increasingly commonly, trial by media or criminal prosecution. The effects of these “hits” can increase the impact for the second victim of an adverse event or outcome [12–15] though some positive outcomes have also been identified [16]. (Table 1). In one study, the clear majority (80%) described a determination to improve because of an adverse event [17]. More recently the Institute for Healthcare Improvement [18] published a white paper on “Respectful management of serious clinical adverse events.” Three priorities were described the first being to care for the patient and their families, who are the direct victims of the event or error. The second was to deal with the healthcare victims the frontline victims. A third priority is to deal with the needs of the organization that can also become victims of the event the third victim. We have chosen to call this the “Domino effect” [19] More recently an alternative “Domino effect” has been proposed in opinion pieces [20,21], where the proposed third victims are clinicians’ friends and families and the proposed fourth victims are future patients. This article aims to be a narrative review of the evidence base for the second victim, focusing on the second victim in maternity healthcare. Extensive and systematic searching of multiple sources was performed by the three authors. Sources included databases (MEDLINE, EMBASE, CINAHL), hand searching journals, guidelines, conference proceedings, opinion articles and literature reviews. Searching was performed in January 2016 and again in January 2017. Databases were searched using the PICO framework (participants, interventions, comparison and outcome) as appropriate. No language restrictions were applied. Prevalence and Risk Factors The phenomenon of the second victim is common, with a prevalence of anything between 10% [22], to 72.6% [14,15,23] of all healthcare practitioners, depending on the group sampled. It should be noted that as systematic sample was not performed in these papers that true prevalence is unknown and it is unfair to perform direct comparisons. As such the following comments are made lightly without inference to the specialties reported. The highest rate reported were hospital staff in Spain, with nearly three quarters of staff reporting that they had experienced the second victim experience either directly or via a colleague within the previous five years [14]. Fellows and members of the Royal College of Physicians self-reported a rate of 63%, the first large-scale UK survey to describe the experiences of physicians in relation to adverse patient events [15]. The lowest reported rate of emotional reactions to errors or events was within otolaryngologists in the US22. Reactions are influenced by both the outcome of the error and the degree of personal responsibility the clinician felt [24–27] (Table 2). Stress may be higher if the incidents involve young, healthy people and multiple lives [25]–a perfect analogy to the labour ward.
Table 1 Reported Experiences of Second Victim. Common Guilt Anxiety Fatigue Frustration Anger Difficulty concentrating Self- Doubt Less Common Reliving event/post-traumatic stress disorder (PTSD) Avoidance of patient care Severe anxiety about return to work Depression Suicidal Ideation
Improved professional relationships Improved communication Determination to further improve
B. Coughlan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 213 (2017) 11–16 Table 2 Risk factors for Development of Second Victims. Poor Outcome(s) to patient(s) High level of personal responsibility for affected patient Young, previously healthy patients Multiple patient lives Female healthcare professional Institutions handling of error Culture of safety and disclosure
Trainees are not exempt with reports of reduction in quality of life, worsening burn-out, increased positive screening for depression, depersonalization, emotional exhaustion, and lower personal accomplishment [28]. In a subsequent article in the New York Times, one author of the study explained some of this as “you can’t go through training without making an error unless you are not taking care of patients” and “if you are really invested in the care of patients, there’s a personal cost when things don’t go well.” [29]. These quotes resonate for many working in maternity healthcare. In another study of trainees [30], of ninety-nine respondents to a survey studying disclosure and patient safety, mistakes were classified as medication related (27%), procedure related (12%), delayed diagnosis (11%) or inadequate follow up of a test (9%). Some of the mistakes had no consequences to the patients; others resulted in delayed treatment, delayed diagnosis, prolonged hospital stay, medical complications, and for some (13%), death. Residents attributed their errors to being too busy, inexperience, having inadequate knowledge, hesitation and tiredness. Thirty residents apologized for the situation associated with the error; seventeen residents disclosed the mistake to the patient or their family. The words used to disclose mistakes should be “chosen carefully”[31] so as to prevent further harm. This concept that residents may be more likely to apologise for a situation than disclose they played a part in causing the poor outcome may be described as “partial disclosure”. Similar results were found in a study of thirty-seven paediatric residents [32] that reviewed factors that influence disclosure (Table 3). Non-consultant trainee doctors are not the only trainees that can be affected in a study of medical student’s exposure to medical errors, 18% had committed an error during clinical rotations, and 76% had observed an error [33]. Second victim in maternity care There are several studies that have reviewed the impact on staff of adverse outcomes and medical errors in maternity care, though it is difficult to distinguish between effect based on error and effect based on the severity of the outcome. A pilot qualitative research study of fourteen healthcare professionals in the UK aimed to explore the impact of maternal death on maternity professionals [8]. A common theme was the devastating effect of maternal death on the professionals themselves, who felt guilt, shame, blame and grief. Most obstetricians interviewed felt that training had helped prepare them for the death, and midwives felt that prior nursing experience (for example, with preparing a body after death) was likely to be valuable. Many, though reluctant to talk about the
Table 3 Factors reported that may influence disclosure of errors [28]. Degree of responsibility for the error Quality of team relationships Exposure to training on disclosure Position within the hierarchy Existence of social boundaries Previous Experience
13
effects of the maternal death, recognized the importance of giving clinicians the opportunity to grieve and the support of colleagues. Some accepted that the professional grief would be long lasting: “I don’t think it is a good idea to forget”. A recently published study of Australian midwives reported the majority (67.2%) had witnessed a traumatic birth event. Feelings of horror and guilt about what happened to the woman were common, and significantly more likely if care-related features were present. 17% of midwives surveyed met the criteria for PTSD [34]. These are similar findings to another study from Sweden, where 15% of obstetricians and midwives reported PTSD after their worst obstetric event. Those with partial PTSD were more likely to change their work to outpatient care [35]. In Denmark, a large survey of obstetricians and midwives revealed that 85% had been involved in a traumatic delivery (defined in this study as one where the mother or infant suffered severe and possibly fatal injuries related to labour and birth). The internal trauma of guilt and shame were more common than external traumas of blame and review [36]. A significantly positive finding from the study was that 65% of respondents felt that they became a better midwife or doctor due to the traumatic incident. The impacts of these events are not just limited amongst staff to midwifery and obstetrics the impact of perinatal death on healthcare chaplains identified similar themes, including their own personal suffering in the presence of parental grief as well as doubt in personal belief structures [37]. The consistency of results from these studies [34–37]suggests that second victims are highly prevalent in maternity care. There is now a call for further research into construction of support systems in maternity care [36] to clarify how “present risk investigation, compensation or negligence schemes for avoidably damaged individuals impact on birth culture, staff turnover and morale” [8]. The Fall Out
As well as the effect on the individual clinician, there are significant concerns about the effect on subsequent patient care to both the affected patient and others. For the affected patient, the therapeutic relationship can be harmed, leaving the patient, family and caregivers to suffer alone [38]. For other, previously unaffected patients, this may cause future harm “as young clinicians who perceive that they have made patient errors in the past demonstrate less empathy and feelings. They are then at risk for subsequent errors. Those who are depressed are two times more likely to make additional errors” [28]. If the quality and satisfaction of patient care is directly impacted by caregiver satisfaction then by supporting care providers directly the long-term benefits could improve emotional support to other patients and families [39]. Debriefing Following an error, or critical incident, there are two equally important components of debriefing providing emotional support to staff and then learning from the event. The oft-used morbidity and mortality conferences, which aim to learn from the event, can focus on the negative, and may themselves cause significant harm to the second victims [40]. Morbidity and mortality meetings could include a ‘safety and success’ section where examples of good performance are discussed [41] celebrating the fact that things go right far more often than they go wrong, as celebrating examples of good practice does not feature heavily in most safety promotion activities. For the second victim, five rights have been proposed treatment, respect, understanding and compassion, supportive care and transparency as well as an opportunity to contribute to enhancing systems of care promoted as the “TRUST” model [42]. Providing emotional support, looking for system errors and
14
B. Coughlan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 213 (2017) 11–16
involving the second victims in investigations will meet these rights. Focusing on the effect of the error on both the clinicians (the second victims) as well as the institution (the third victim) can highlight the need to support others. Emotional and factual debriefing sessions should be a fundamental part of critical incident management. Ideally these should compose of a peer driven, therapist guided group approach, designed to promote recovery, assist in accelerating readjustment and prevent potential long term effects [43,12]. The Mitchell debriefing model has also been proposed as a method to reduce stress and restore the emotional and physical health of staff [44] 44. With the introduction of “Being Open” (in the UK) [45] and “Open Disclosure” (in the Republic of Ireland) [46] this may help with the use of disclosure as a part of the strategy of coping as a second victim, though the disclosure and apology needs to be authentic to maintain the trust between clinician, individual and family [31]. Coping and Recovery How individual clinicians involve others in their coping strategies can vary between individuals, but the proportions of requirements by staff is consistent across the studies, with the majority seeking discussion with peers rather than external agencies. (Fig. 1) [1,2,4,6–8]. In providing this support on an individual basis, it is important to have a trusting relationship, have the conversation early and to show trust in the individual. Without this foundation, these healing conversations may not occur. Concerns about damage to professional relationships mean that between a third and a half of clinicians may not be comfortable in discussing errors with all colleagues [38], as well as concerns that colleagues may avoid emotional concerns or minimize mistakes [49]. In contrast, 40% of clinicians felt adequately supported at their hospital or practice when involved in an adverse event [38]. Questions that have been suggested to ask to start the conversation include “This had to be difficult. How are you doing?”, “You are a good clinician working in a difficult environment” or “Can we talk about this?” [12,40]. In a study of thirty-three people involved in different events, six stages of a recovery trajectory have been described [12], stages that may resonate with many clinicians who have had these experiences. The first was chaos and accident response, where the clinician realizes the error and deals with it, often getting others involved in the care of the patient. After this the next stage is intrusive reflections, the “what ifs?”. A third stage is to attempt to restore personal integrity, by seeking support from others and
from themselves. As questions are asked, the next step is to endure inquisition from others, and wonder about the impact of the error. A further, fifth, step involved obtaining emotional first aid. Depending on the prior five steps, the person them self as an individual, and the organization itself, the final step may involve either dropping out, surviving (just) or thriving as the second victim moves on from the error. Coping strategies can be divided in different ways. Firstly, they can be described as either problem focused or emotional focused. Both can be positively or negatively construed problem focusing on the facts (learning from mistakes, information seeking, determining what transpired, dealing with the problem itself) and emotional focusing on the feelings (managing the emotional distress caused by the error, accepting responsibility) [48–50]. Talking to medical colleagues may be more useful than talking to friends and family [24] 24, this again may support the view that discussion with colleagues may be one of the most useful popular strategies. A second division of coping strategies can involve changes in practice, which may be either defensive (denial, distancing, discounting) [48,51] or constructive (accepting responsibility and planning problem solving) [50]. A third division is that of shame and guilt shame reflecting a failure of one’s whole self, prompting a desire to hide, and guilt usually associated with an event, where the prompt is to make amends [52]. In an editorial on medical errors [53] confession, restitution and absolution were described as means to deal with guilt, though the option of confession may not be available because of fear of litigation or a forum may not be available. Interestingly, a study of medical students showed that those who witnessed senior doctors take responsibility for errors and candidly disclose errors to patients appeared to recognise the importance of honesty and integrity and said they aspired to these standards the students saw these doctors as role models [33]. Experience of reporting Of those who have used formal incident reporting systems, the majority in one study reported dissatisfaction with the process. Only a small minority (14%) received useful feedback. Others saw local improvements or system changes, but these were again in the minority [15]. Some described a double standard, with specific groups being reported, but not others [22]. Those with negative experiences of investigations, or punitive experiences, are less likely to report future incidents. If senior, their attitude to reporting may influence the behaviour of junior staff. It is interesting to note that the study with the lowest prevalence of second victims amongst American otolaryngologists had a high rate of corrective actions [22]. Actions for correction of the error included ameliorating the consequences of the event to the patient (50%), improvements in respondents practice or department (28%), hospital wide or broader corrective action, disclosure to the patient and personal practice change. New ways of promoting safety are emerging involving the study and promotion of success rather than failure, at the heart of which is the concept of resilience [54]. Resilience
Fig. 1. Supports reported as required and useful by Second Victims.
The need to retain composure and maintain high performance levels in the face of adversity is essential for those in the Maternity setting. The ability of a clinician to remain resilient following an adverse outcome to mother or baby is a product of their individual characteristics and the environment in which they work [10]. Adequate support can reduce the distress felt by the clinician while a lack of support can add to the trauma felt [12]. At the first recognition that an adverse event has occurred, the emotional and
B. Coughlan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 213 (2017) 11–16
psychological effects on the clinician begin [55] 55, therefore it is essential that healthcare workers can anticipate threats, adapt accordingly and learn from both good and bad performance [10] 0. The desired healthcare environment is one where staff members are resilient and mutually supportive before, during and after adverse events [56] thus lessening the likelihood of further harm. System support Systems have been set up to help second victims, including individual institutions (University of Missouri [12] the Brigham and Women’s Peer Support team [47] Johns Hopkins Hospital [65]) and independent organizations (the Medically induced trauma supports system, MITSS [57]). We are unaware of any national system for care of the second victims other than the national framework (“ASSIST-ME”) [58] in the Republic of Ireland. A recent review [59] concluded with a quote summarizes the importance of caring for the second victim, support that needs to be a system wide responsibility to be truly effective [17]. “health care workers who get wrapped up in error and injury, as almost all someday will, get seriously hurt too. And if we’re healers, then we have a job of healing them too. That’s part of the job. It’s not an elective issue, it’s an ethical issue”. Providing a balance It has been proposed to balance the reactive approach to safety (labeled as “Safety I” [54] with a “Safety II” approach, where we learn instead from all episodes of successful healthcare interactions. Most healthcare interactions occur despite variable conditions, and are often based on workaround and improvisation. Allied to the Safety II movement is the concept of “Learning from Excellence” (LfE), where a pilot project of LfE within a paediatric intensive care unit has now resulted in over 700 reports of excellence [41]. Excellence reporting has been shown to improve staff morale and improve quality of care, as well as increasing the rate of “gold standard” prescribing from 18% to 35%, and improving practice in delivery of care. The group has also started looking at positive feedback from families, using appreciative inquiry [60] to support staff and ultimately improve patient care.
Conclusion Maternity care is an imperfect art, where adverse outcomes and errors will occur. Three groups may potentially be affected when errors and adverse outcomes occur. The first, and central group, are women, their babies and their families. Care must be provided continuously and at the highest level of quality. The second groupthe second victims- is the healthcare workers themselves. The experiences of second victims are largely negative fear, guilt, shame, physical symptoms, depression, PTSD- and occasionally and tragically end in self-harm and suicide. Some of the effects of second victimhood may indeed be positive increased assertiveness, communication with others, changes in patient care and willingness to learn. The final group- the third victims- is the organizations where the event occurs. With some high-profile medical outcomes and errors the effect of this error can result in negative implications on the organization for years. It is clearly shown that when staff members are supported in their disclosure of errors this domino effect is less common, and disclosure is more likely. It is the responsibility of everyone working in healthcare to support all the victims of an error, as an ethical duty and to have a supportive culture of disclosure. In addition, balance can be provided by developing a culture of learning from excellence as well as from mistakes.
15
ACKNOWLEDGEMENTS Nil. References [1] To err is human: Building a safer health system. In: Kohn T, Corrigan JM, Donaldson MS, editors. Washington, DC: National Academy Press; 1999. [2] Makary M, Daniel M. Medical error–the third leading cause of death in the US. BMJ 2016;353:i2139. [3] Saving Lives, Improving Mothers’ Care – Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–13. In: Knight M, Tuffnell D, Kenyon S, Shakespeare J, Gray R, Kurinczuk JJ, on behalf of MBRRACE-UK, editors. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2015. [4] Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gynaecol 2007;109:48–55. [5] Cornthwaite K, Edwards S, Siassakos D. Reducing risk in maternity by optimizing teamwork and leadership: an evidence-based approach to save mothers and babies. Best Pract Res Clin Obstet Gynaecol 2013;27(4):571–81. [6] Edozien LC. Situational awareness and its application in the Delivery Suite. Obstetrics & Gynecology 2015;125:65–9. [7] Meaney S, Cussen L, Greene RA, O’Donoghue K. Reaction on Twitter to a Cluster of Perinatal Deaths: a Mixed Method Study. JMIR Public Health Surveill. 2016;27(2):e36. [8] Cauldwell M, Chappell LC, Murtagh G, Bewley S. Learning about maternal death and grief in the profession: a pilot qualitative study. Acta Obstet Gynecol Scand 2015;94(12):1346–53. [9] Leape LL. Error in Medicine. JAMA 1994;272(23):1851–8. [10] Santomauro CM, Kalkman CJ, Dekker S. Second victims, organizational resilience and the role of hospital administration. J Hos Admin 2014;3(5):95– 104. [11] Wu AW. Medical error: the second victim: The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726–7. [12] Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. The Joint Commission Journal on Quality and Patient Safety 2010;36(5):233–40. [13] Hilfiker D. Facing our mistakes. N Engl J Med. 1984;310(2):118–22. [14] Mira JJ, Carrillo I, Lorenzo S, et al. The aftermath of adverse events in Spanish primary care and hospital health professionals. BMC Health Services Research 2015;15:151–60. [15] Harrison R, Lawton R, Stewart K. Doctors experiences of adverse events in secondary care: the professional and personal impact. Clin Med 2014;14:585– 90. [16] 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 professionals’ psychological well-being. Qual Saf Health Care 2010;19:e43. [17] Stewart K, Lawton R, Harrison R. Supporting second victims is a system-wide responsibility. BMJ 2015;350:h2341. [18] Conway J, Federico F, Stewart K, Campbell M. Respectful management of serious clinical adverse events. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2010. [19] M. Higgins. The second victim in modern healthcare. BMJ Blogs. Accessed on March 6th 2017 from http://blogs.bmj.com/bmj/2016/08/22/mary-higginsthe-second-victim-in-modern-healthcare/. [20] Plunkett A. Presentation at the Social Media and Critical Care Conference. Accessed on March 7th from http://learningfromexcellence.com/videos/. [21] Higgins M. The echoes of past events. Accessed on March 6th 2017 fromhttp:// blogs.bmj.com/bmj/2017/03/02/how-the-ghost-of-patients-past-have-adeeper-impact-than-we-may-think/. [22] Lander LI, Connor JA, Shah RK, Kentala E, Healy GB, Roberson DW. Otolaryngologists’ responses to errors and adverse events. Laryngoscope 2006;116:1114–20. [23] Wolf ZR, Serembus JF, Smetzer J, Cohen H, Cohen M. Responses and concerns of healthcare providers to medication errors. Clinical Nurse Specialist 2000;14:278–87. [24] Engel KG, Rosenthal M, Sutcliffe KM. Residents’ responses to medical error: Coping, learning, and change. Academic Medicine 2006 2006;81:86–93. [25] Marmar CR, Weiss DS, Metzler TJ, Ronfeldt HM, Foreman C. Stress responses of emergency services personnel to the Loma Prieta earthquake Interstate 880 freeway collapse and control traumatic incidents. J Trauma Stress 1996;9:63– 85. [26] Kaldjian LC, Forman-Hoffman VL, Jones EW, Wu BJ, Levi BH, Rosenthal GE. Do faculty and resident physicians discuss their medical errors? Journal of Medical Ethics 2008;34:717–22. [27] Muller D, Ornstein K. Perceptions of and attitudes towards medical errors among medical trainees. Medical Education 2007;41:645–52. [28] West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy. JAMA. 2006;296(9):1071–8. [29] Chen PW. Doctor and patient: when doctors make mistakes. New York Times; 2017 July 9, 2009. Accessed March 6th 2017 from:http://nytimes.com/2009/ 07/09/health/09chen.html..
16
B. Coughlan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 213 (2017) 11–16
[30] Kronman AC, Paasche-Orlow M, Orlander JD. Factors associated with disclosure of medical errors by housestaff. BMJ Qual Saf 2012;21(4):271–8. [31] Gallagher TH, Waterman AD, Ebers AG, et al. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA 2003;289:1001–7. [32] Coffey M, Thomson K, Tallet S, Matlow A. Pediatric residents decision-making around disclosing and reporting adverse events: the importance of social context. Acad Med 2010;85(10):1619–25. [33] Martinez W, Lo B. Medical students’ experiences with medical errors: An analysis of medical student essays. Medical Education 2008;42:733–41. [34] Leinweber J, Creedy DK, Rowe H, Gamble J. Responses to birth trauma and prevalence of posttraumatic stress among Australian midwives. Women Birth 2016(July), doi:http://dx.doi.org/10.1016/j.wombi.2016.06.006. [35] Wahlberg A, Saches A, Johannesson K, et al. Post-traumatic stress symptoms in Swedish obstetricians and midwives after severe obstetric events: a cross sectional retrospective survey. BJOG 2016, doi:http://dx.doi.org/10.1111/14710528.14259. [36] Schrøder K, Larsen PV, Jørgensen JS, Hjelmborg JV, Lamont RF, Hvidt NC. Psychosocial health and well-being among obstetricians and midwives involved in traumatic childbirth. Midwifery 2016;41:45–53. [37] Nuzem D, Meaney S, O’Donoghue K, Morris H. The spiritual and theological issues raised by stillbirth for healthcare chaplins. J Pastoral Care Counsel 2015;69(3):163–70. [38] Bell SK, Moorman DW, Delbanco T. Improving the patient, family, and clinician experience after harmful events: The “when things go wrong” curriculum. Academic Medicine 2010;85:1010–7. [39] Clemmer J. Customer satisfaction is a reflection of employee satisfaction. Accessed March 6th 2017 from: http://www.clemmergroup.com/articles/ customer-satisfaction-reflection-employee-satisfaction/. [40] Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf. 2011;21(April (4))267– 70, doi:http://dx.doi.org/10.1136/bmjqs-2011-000605 Epub 2012 Jan 2. [41] Kelly N, Blake S, Plunkett A. Learning from excellence in healthcare: a new approach to incident reporting. Arch Dis Child 2016;101(9):788–91. [42] Denham,. C.R TRUST: the 5 rights of the second victim. Journal of Patient Safety 2007;3(2):107–19. [43] Vaithilingam N, Jain S, Davies D. Helping the helpers: debriefing following an adverse incident. The Obstetrician and Gynaecologist 2008;10:251–6. [44] Mitchell JT, Everly Jr. GS. Critical Incident Stress Debriefing: (CISD). Ellicott City Md: Chevron Publishing Co; 1993.
[45] Birks Y, Harrison R, Bosanquet K, et al. An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review and qualitative exploration. Health Serv and Delivery Research 2016;2:20. [46] Open Disclosure - National Guidelines. Communicating with service users and their families following adverse events in healthcare. HSE, Dublin, 2013. [47] van Pelt F. Peer support: healthcare professionals supporting each other after adverse medical events. Qual Saf Health Care 2008;17:249–52. [48] Wu AW, Folkman S, McPhee SJ, Lo B. How house officers cope with their mistakes. Western Journal of Medicine 1993;159:565–9. [49] Christensen JF, Levinson W, Dunn PM. The heart of darkness: The impact of perceived mistakes on physicians. J Gen Int Med 1993;7:424–31. [50] Chard R. How perioperative nurses define, attribute causes of, and react to intraoperative nursing errors. AORN Journal 2010;91:132–45. [51] Meurier CE, Vincent CA, Parmar DG. Nurses’ responses to severity dependent errors. Journal of Advanced Nursing 1993;27:349–54. [52] Ofri D. Ashamed to admit it: owning up to medical error. Health Aff (Millwood). 2010;29(8):1549–51. [53] Weiss P. Medical Errors and the second victim. The female patient 2011;36:29– 32. [54] Resilient Health Care. In: Hollnagel E, Braithwaite J, Wears RL, editors. Farnham, UK: Ashgate; 2013. [55] Pettker CM, Funai EF. Getting it right when things go wrong. JAMA 2010;303 (10):856–977. [56] Edrees H, Connors C, Paine L, Norvell M, Taylor H, Wu AW. Implementing the RISE second victim support programme at the Johns Hopkins Hospital. a case study 2016;6(September (9)):e011708. [57] Medically Induced Trauma Support System. Accessed on March 6th 2017 at http://www.mitss.org. [58] ASSIST-ME model: supporting staff following an adverse event. Accessed on March 6th 2017 at: http://www.hse.ie/eng/about/Who/qualityandpatientsafety/nau/Open_Disclosure/opendiscFiles/bookletSuppStaffadverseevent.pdf. [59] Seys D, Wu A, Van Gerven E, Vleugels A, Euwema M, Panella M, Scott S, Conway J, Sermeus W, Vanhaecht K. Health Care Professionals as Second Victims after Adverse Events: A Systematic Review. Evaluation & the Health Professions 2016;36(2):135–62. [60] Cooperrider DL, Whitney D. A positive revolution in change: appreciative inquiry. Public Adm Public Policy 2001;87:611–30.
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Review article
The Second Victim: a Review B. Coughlana , D. Powellb,* , M.F. Higginsc,* a
UCD Midwifery, School of Medicine, University College Dubli, Republic of Ireland Department of Risk Management, Connolly Hospital, Dublin c Perinatal Research Center, UCD Obstetrics and Gynaecology, School of Medicine, National Maternity Hospital, University College Dublin, Republic of Ireland b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 16 January 2017 Received in revised form 7 March 2017 Accepted 1 April 2017
Amongst the lay and media population there is a perception that pregnancy, labour and delivery is always physiological, morbidity and mortality should be “never events” and that error is the only cause of adverse events. Those working in maternity care know that it is an imperfect art, where adverse outcomes and errors will occur. When errors do occur, there is a domino effect with three groups being involved the patient (first victim), the staff (second victims) and the organization (third victims). If the perceived expectation of patients on all clinicians is that of perfection, then clinicians may suffer the consequences of adverse outcomes in isolation and silence. More recently identification and discussion on the phenomenon of the second victim has become a popular research topic. This review aimed to study not only the phenomenon of second victim in general medical care but to also concentrate on maternity care where the expectation of perfection may be argued to be greater. Risk factors, prevalence and effect of second victims were identified from a thorough search of the literature on the topic. The review focuses on the recent research of the effect on maternity staff of adverse outcomes and discusses topical issues of resilience, disclosure, support systems as well as Learning from Excellence. It is now well documented that when staff members are supported in their disclosure of errors this domino effect is less traumatic. It is the responsibility of everyone working in healthcare to support all the victims of an error, as an ethical duty and to have a supportive culture of disclosure. In addition, balance can be provided by developing a culture of learning from excellence as well as from errors. © 2017 Elsevier B.V. All rights reserved.
Keywords: Second Victim Domino Effect Maternity
Contents Debriefing . . . . . . . . . . . Coping and Recovery . . Experience of reporting Resilience . . . . . . . . . . . System support . . . . . . . Providing a balance . . . Conclusion . . . . . . . . . . ACKNOWLEDGEMENTS References . . . . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
Medicine is an imperfect art. Sixteen years ago it was estimated that medical errors caused up to 98,000 deaths per year in the
* Corresponding author. Mary Higgins, UCD Obstetrics and Gynaecology, 65–66 Lower Mount Street, Dublin 2, Republic of Ireland. E-mail address: [email protected] (B. Coughlan). http://dx.doi.org/10.1016/j.ejogrb.2017.04.002 0301-2115/© 2017 Elsevier B.V. All rights reserved.
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
13 14 14 14 15 15 15 15 15
United States [1], at the time considered the fourth most common cause of death. More recently it has been suggested that this may be an underestimation, as previous studies rely on errors extractable from health records, include only inpatients, or, in the United States, rely on cause of death based on International Classification of Disease (ICD) codes that do not capture human or system factors [2]. The current best estimation is that medical error
12
B. Coughlan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 213 (2017) 11–16
is the now the third biggest cause of death in the US [2], with a mean rate of death from medical error of 251,454/year. Maternity care, as a discipline within medicine, is also an imperfect art. Though the rate of mortality in maternity care is low, some maternal deaths in the United Kingdom and Ireland have been associated with sub-standard care [3] 3. With regard to morbidity, one in twelve labours can result in adverse outcome to mother or baby [4] 4. Contributory factors including patient demographics, work overload, task saturation, distractions, poor teamwork, sub-optimal communication, mental models, fixation and lack of leadership, as well as situational awareness may not have always caused the adverse outcome but may contribute to the response to the outcome and may result in an implication of medical error [5] 5. This is further confounded by a widespread perception amongst the lay population and the media that pregnancy, labour and delivery are always physiological, deaths should be “never events” and that error is the only cause of adverse events in maternity care [7]. There is a perception that the general public have an “expectation that childbirth was a jubilant event and to suggest any possible harm to the mother was met with incredulity” [8]. Healthcare professionals are conditioned to function at a high level of proficiency with the emphasis on perfection [9] 9 Society too tends to expect of clinicians an image of perfection, which can lead to the clinician having to suffer the consequences of a mistake in silence and isolation [10]. In the same year as Kohn estimated the rate of medical error, Albert Wu coined the term “second victim”. Wu described medicine as an imperfect science, as “many errors are built into existing routines and devices, setting up the unwitting physician and patient for disaster” [11], despite the expectation of near perfection by patients, clinicians and administrators. While acknowledging the crucial importance that the patient must always come first “although patients are the first and obvious victims of medical mistakes”- he also acknowledged the effect of error on clinicians, who “are wounded by the same errors: they are the second victims”. The definition was further refined nine years later, with the second victim being described as ‘A health care provider involved in an unanticipated adverse patient event, medical error, and/or a patient related–injury who become victimized in the sense that the provider is traumatized by the event. Frequently second victims feel personally responsible for the unexpected patient outcomes and feel as though they have failed their patient, second guessing their clinical skills and knowledge base’ [12]. An “intolerable paradox” has been described of the clinician who makes a mistake -“we see the horror of our own mistakes, yet, we are given no permission to deal with their enormous emotional impact . . . . the medical profession simply has no place for its mistakes” [13]. The effect of an error can have an enormous emotional, professional and personal drain [11], whether this involves personal or local review, litigation, coroners’ inquest, court, or
increasingly commonly, trial by media or criminal prosecution. The effects of these “hits” can increase the impact for the second victim of an adverse event or outcome [12–15] though some positive outcomes have also been identified [16]. (Table 1). In one study, the clear majority (80%) described a determination to improve because of an adverse event [17]. More recently the Institute for Healthcare Improvement [18] published a white paper on “Respectful management of serious clinical adverse events.” Three priorities were described the first being to care for the patient and their families, who are the direct victims of the event or error. The second was to deal with the healthcare victims the frontline victims. A third priority is to deal with the needs of the organization that can also become victims of the event the third victim. We have chosen to call this the “Domino effect” [19] More recently an alternative “Domino effect” has been proposed in opinion pieces [20,21], where the proposed third victims are clinicians’ friends and families and the proposed fourth victims are future patients. This article aims to be a narrative review of the evidence base for the second victim, focusing on the second victim in maternity healthcare. Extensive and systematic searching of multiple sources was performed by the three authors. Sources included databases (MEDLINE, EMBASE, CINAHL), hand searching journals, guidelines, conference proceedings, opinion articles and literature reviews. Searching was performed in January 2016 and again in January 2017. Databases were searched using the PICO framework (participants, interventions, comparison and outcome) as appropriate. No language restrictions were applied. Prevalence and Risk Factors The phenomenon of the second victim is common, with a prevalence of anything between 10% [22], to 72.6% [14,15,23] of all healthcare practitioners, depending on the group sampled. It should be noted that as systematic sample was not performed in these papers that true prevalence is unknown and it is unfair to perform direct comparisons. As such the following comments are made lightly without inference to the specialties reported. The highest rate reported were hospital staff in Spain, with nearly three quarters of staff reporting that they had experienced the second victim experience either directly or via a colleague within the previous five years [14]. Fellows and members of the Royal College of Physicians self-reported a rate of 63%, the first large-scale UK survey to describe the experiences of physicians in relation to adverse patient events [15]. The lowest reported rate of emotional reactions to errors or events was within otolaryngologists in the US22. Reactions are influenced by both the outcome of the error and the degree of personal responsibility the clinician felt [24–27] (Table 2). Stress may be higher if the incidents involve young, healthy people and multiple lives [25]–a perfect analogy to the labour ward.
Table 1 Reported Experiences of Second Victim. Common Guilt Anxiety Fatigue Frustration Anger Difficulty concentrating Self- Doubt Less Common Reliving event/post-traumatic stress disorder (PTSD) Avoidance of patient care Severe anxiety about return to work Depression Suicidal Ideation
Improved professional relationships Improved communication Determination to further improve
B. Coughlan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 213 (2017) 11–16 Table 2 Risk factors for Development of Second Victims. Poor Outcome(s) to patient(s) High level of personal responsibility for affected patient Young, previously healthy patients Multiple patient lives Female healthcare professional Institutions handling of error Culture of safety and disclosure
Trainees are not exempt with reports of reduction in quality of life, worsening burn-out, increased positive screening for depression, depersonalization, emotional exhaustion, and lower personal accomplishment [28]. In a subsequent article in the New York Times, one author of the study explained some of this as “you can’t go through training without making an error unless you are not taking care of patients” and “if you are really invested in the care of patients, there’s a personal cost when things don’t go well.” [29]. These quotes resonate for many working in maternity healthcare. In another study of trainees [30], of ninety-nine respondents to a survey studying disclosure and patient safety, mistakes were classified as medication related (27%), procedure related (12%), delayed diagnosis (11%) or inadequate follow up of a test (9%). Some of the mistakes had no consequences to the patients; others resulted in delayed treatment, delayed diagnosis, prolonged hospital stay, medical complications, and for some (13%), death. Residents attributed their errors to being too busy, inexperience, having inadequate knowledge, hesitation and tiredness. Thirty residents apologized for the situation associated with the error; seventeen residents disclosed the mistake to the patient or their family. The words used to disclose mistakes should be “chosen carefully”[31] so as to prevent further harm. This concept that residents may be more likely to apologise for a situation than disclose they played a part in causing the poor outcome may be described as “partial disclosure”. Similar results were found in a study of thirty-seven paediatric residents [32] that reviewed factors that influence disclosure (Table 3). Non-consultant trainee doctors are not the only trainees that can be affected in a study of medical student’s exposure to medical errors, 18% had committed an error during clinical rotations, and 76% had observed an error [33]. Second victim in maternity care There are several studies that have reviewed the impact on staff of adverse outcomes and medical errors in maternity care, though it is difficult to distinguish between effect based on error and effect based on the severity of the outcome. A pilot qualitative research study of fourteen healthcare professionals in the UK aimed to explore the impact of maternal death on maternity professionals [8]. A common theme was the devastating effect of maternal death on the professionals themselves, who felt guilt, shame, blame and grief. Most obstetricians interviewed felt that training had helped prepare them for the death, and midwives felt that prior nursing experience (for example, with preparing a body after death) was likely to be valuable. Many, though reluctant to talk about the
Table 3 Factors reported that may influence disclosure of errors [28]. Degree of responsibility for the error Quality of team relationships Exposure to training on disclosure Position within the hierarchy Existence of social boundaries Previous Experience
13
effects of the maternal death, recognized the importance of giving clinicians the opportunity to grieve and the support of colleagues. Some accepted that the professional grief would be long lasting: “I don’t think it is a good idea to forget”. A recently published study of Australian midwives reported the majority (67.2%) had witnessed a traumatic birth event. Feelings of horror and guilt about what happened to the woman were common, and significantly more likely if care-related features were present. 17% of midwives surveyed met the criteria for PTSD [34]. These are similar findings to another study from Sweden, where 15% of obstetricians and midwives reported PTSD after their worst obstetric event. Those with partial PTSD were more likely to change their work to outpatient care [35]. In Denmark, a large survey of obstetricians and midwives revealed that 85% had been involved in a traumatic delivery (defined in this study as one where the mother or infant suffered severe and possibly fatal injuries related to labour and birth). The internal trauma of guilt and shame were more common than external traumas of blame and review [36]. A significantly positive finding from the study was that 65% of respondents felt that they became a better midwife or doctor due to the traumatic incident. The impacts of these events are not just limited amongst staff to midwifery and obstetrics the impact of perinatal death on healthcare chaplains identified similar themes, including their own personal suffering in the presence of parental grief as well as doubt in personal belief structures [37]. The consistency of results from these studies [34–37]suggests that second victims are highly prevalent in maternity care. There is now a call for further research into construction of support systems in maternity care [36] to clarify how “present risk investigation, compensation or negligence schemes for avoidably damaged individuals impact on birth culture, staff turnover and morale” [8]. The Fall Out
As well as the effect on the individual clinician, there are significant concerns about the effect on subsequent patient care to both the affected patient and others. For the affected patient, the therapeutic relationship can be harmed, leaving the patient, family and caregivers to suffer alone [38]. For other, previously unaffected patients, this may cause future harm “as young clinicians who perceive that they have made patient errors in the past demonstrate less empathy and feelings. They are then at risk for subsequent errors. Those who are depressed are two times more likely to make additional errors” [28]. If the quality and satisfaction of patient care is directly impacted by caregiver satisfaction then by supporting care providers directly the long-term benefits could improve emotional support to other patients and families [39]. Debriefing Following an error, or critical incident, there are two equally important components of debriefing providing emotional support to staff and then learning from the event. The oft-used morbidity and mortality conferences, which aim to learn from the event, can focus on the negative, and may themselves cause significant harm to the second victims [40]. Morbidity and mortality meetings could include a ‘safety and success’ section where examples of good performance are discussed [41] celebrating the fact that things go right far more often than they go wrong, as celebrating examples of good practice does not feature heavily in most safety promotion activities. For the second victim, five rights have been proposed treatment, respect, understanding and compassion, supportive care and transparency as well as an opportunity to contribute to enhancing systems of care promoted as the “TRUST” model [42]. Providing emotional support, looking for system errors and
14
B. Coughlan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 213 (2017) 11–16
involving the second victims in investigations will meet these rights. Focusing on the effect of the error on both the clinicians (the second victims) as well as the institution (the third victim) can highlight the need to support others. Emotional and factual debriefing sessions should be a fundamental part of critical incident management. Ideally these should compose of a peer driven, therapist guided group approach, designed to promote recovery, assist in accelerating readjustment and prevent potential long term effects [43,12]. The Mitchell debriefing model has also been proposed as a method to reduce stress and restore the emotional and physical health of staff [44] 44. With the introduction of “Being Open” (in the UK) [45] and “Open Disclosure” (in the Republic of Ireland) [46] this may help with the use of disclosure as a part of the strategy of coping as a second victim, though the disclosure and apology needs to be authentic to maintain the trust between clinician, individual and family [31]. Coping and Recovery How individual clinicians involve others in their coping strategies can vary between individuals, but the proportions of requirements by staff is consistent across the studies, with the majority seeking discussion with peers rather than external agencies. (Fig. 1) [1,2,4,6–8]. In providing this support on an individual basis, it is important to have a trusting relationship, have the conversation early and to show trust in the individual. Without this foundation, these healing conversations may not occur. Concerns about damage to professional relationships mean that between a third and a half of clinicians may not be comfortable in discussing errors with all colleagues [38], as well as concerns that colleagues may avoid emotional concerns or minimize mistakes [49]. In contrast, 40% of clinicians felt adequately supported at their hospital or practice when involved in an adverse event [38]. Questions that have been suggested to ask to start the conversation include “This had to be difficult. How are you doing?”, “You are a good clinician working in a difficult environment” or “Can we talk about this?” [12,40]. In a study of thirty-three people involved in different events, six stages of a recovery trajectory have been described [12], stages that may resonate with many clinicians who have had these experiences. The first was chaos and accident response, where the clinician realizes the error and deals with it, often getting others involved in the care of the patient. After this the next stage is intrusive reflections, the “what ifs?”. A third stage is to attempt to restore personal integrity, by seeking support from others and
from themselves. As questions are asked, the next step is to endure inquisition from others, and wonder about the impact of the error. A further, fifth, step involved obtaining emotional first aid. Depending on the prior five steps, the person them self as an individual, and the organization itself, the final step may involve either dropping out, surviving (just) or thriving as the second victim moves on from the error. Coping strategies can be divided in different ways. Firstly, they can be described as either problem focused or emotional focused. Both can be positively or negatively construed problem focusing on the facts (learning from mistakes, information seeking, determining what transpired, dealing with the problem itself) and emotional focusing on the feelings (managing the emotional distress caused by the error, accepting responsibility) [48–50]. Talking to medical colleagues may be more useful than talking to friends and family [24] 24, this again may support the view that discussion with colleagues may be one of the most useful popular strategies. A second division of coping strategies can involve changes in practice, which may be either defensive (denial, distancing, discounting) [48,51] or constructive (accepting responsibility and planning problem solving) [50]. A third division is that of shame and guilt shame reflecting a failure of one’s whole self, prompting a desire to hide, and guilt usually associated with an event, where the prompt is to make amends [52]. In an editorial on medical errors [53] confession, restitution and absolution were described as means to deal with guilt, though the option of confession may not be available because of fear of litigation or a forum may not be available. Interestingly, a study of medical students showed that those who witnessed senior doctors take responsibility for errors and candidly disclose errors to patients appeared to recognise the importance of honesty and integrity and said they aspired to these standards the students saw these doctors as role models [33]. Experience of reporting Of those who have used formal incident reporting systems, the majority in one study reported dissatisfaction with the process. Only a small minority (14%) received useful feedback. Others saw local improvements or system changes, but these were again in the minority [15]. Some described a double standard, with specific groups being reported, but not others [22]. Those with negative experiences of investigations, or punitive experiences, are less likely to report future incidents. If senior, their attitude to reporting may influence the behaviour of junior staff. It is interesting to note that the study with the lowest prevalence of second victims amongst American otolaryngologists had a high rate of corrective actions [22]. Actions for correction of the error included ameliorating the consequences of the event to the patient (50%), improvements in respondents practice or department (28%), hospital wide or broader corrective action, disclosure to the patient and personal practice change. New ways of promoting safety are emerging involving the study and promotion of success rather than failure, at the heart of which is the concept of resilience [54]. Resilience
Fig. 1. Supports reported as required and useful by Second Victims.
The need to retain composure and maintain high performance levels in the face of adversity is essential for those in the Maternity setting. The ability of a clinician to remain resilient following an adverse outcome to mother or baby is a product of their individual characteristics and the environment in which they work [10]. Adequate support can reduce the distress felt by the clinician while a lack of support can add to the trauma felt [12]. At the first recognition that an adverse event has occurred, the emotional and
B. Coughlan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 213 (2017) 11–16
psychological effects on the clinician begin [55] 55, therefore it is essential that healthcare workers can anticipate threats, adapt accordingly and learn from both good and bad performance [10] 0. The desired healthcare environment is one where staff members are resilient and mutually supportive before, during and after adverse events [56] thus lessening the likelihood of further harm. System support Systems have been set up to help second victims, including individual institutions (University of Missouri [12] the Brigham and Women’s Peer Support team [47] Johns Hopkins Hospital [65]) and independent organizations (the Medically induced trauma supports system, MITSS [57]). We are unaware of any national system for care of the second victims other than the national framework (“ASSIST-ME”) [58] in the Republic of Ireland. A recent review [59] concluded with a quote summarizes the importance of caring for the second victim, support that needs to be a system wide responsibility to be truly effective [17]. “health care workers who get wrapped up in error and injury, as almost all someday will, get seriously hurt too. And if we’re healers, then we have a job of healing them too. That’s part of the job. It’s not an elective issue, it’s an ethical issue”. Providing a balance It has been proposed to balance the reactive approach to safety (labeled as “Safety I” [54] with a “Safety II” approach, where we learn instead from all episodes of successful healthcare interactions. Most healthcare interactions occur despite variable conditions, and are often based on workaround and improvisation. Allied to the Safety II movement is the concept of “Learning from Excellence” (LfE), where a pilot project of LfE within a paediatric intensive care unit has now resulted in over 700 reports of excellence [41]. Excellence reporting has been shown to improve staff morale and improve quality of care, as well as increasing the rate of “gold standard” prescribing from 18% to 35%, and improving practice in delivery of care. The group has also started looking at positive feedback from families, using appreciative inquiry [60] to support staff and ultimately improve patient care.
Conclusion Maternity care is an imperfect art, where adverse outcomes and errors will occur. Three groups may potentially be affected when errors and adverse outcomes occur. The first, and central group, are women, their babies and their families. Care must be provided continuously and at the highest level of quality. The second groupthe second victims- is the healthcare workers themselves. The experiences of second victims are largely negative fear, guilt, shame, physical symptoms, depression, PTSD- and occasionally and tragically end in self-harm and suicide. Some of the effects of second victimhood may indeed be positive increased assertiveness, communication with others, changes in patient care and willingness to learn. The final group- the third victims- is the organizations where the event occurs. With some high-profile medical outcomes and errors the effect of this error can result in negative implications on the organization for years. It is clearly shown that when staff members are supported in their disclosure of errors this domino effect is less common, and disclosure is more likely. It is the responsibility of everyone working in healthcare to support all the victims of an error, as an ethical duty and to have a supportive culture of disclosure. In addition, balance can be provided by developing a culture of learning from excellence as well as from mistakes.
15
ACKNOWLEDGEMENTS Nil. References [1] To err is human: Building a safer health system. In: Kohn T, Corrigan JM, Donaldson MS, editors. Washington, DC: National Academy Press; 1999. [2] Makary M, Daniel M. Medical error–the third leading cause of death in the US. BMJ 2016;353:i2139. [3] Saving Lives, Improving Mothers’ Care – Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–13. In: Knight M, Tuffnell D, Kenyon S, Shakespeare J, Gray R, Kurinczuk JJ, on behalf of MBRRACE-UK, editors. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2015. [4] Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gynaecol 2007;109:48–55. [5] Cornthwaite K, Edwards S, Siassakos D. Reducing risk in maternity by optimizing teamwork and leadership: an evidence-based approach to save mothers and babies. Best Pract Res Clin Obstet Gynaecol 2013;27(4):571–81. [6] Edozien LC. Situational awareness and its application in the Delivery Suite. Obstetrics & Gynecology 2015;125:65–9. [7] Meaney S, Cussen L, Greene RA, O’Donoghue K. Reaction on Twitter to a Cluster of Perinatal Deaths: a Mixed Method Study. JMIR Public Health Surveill. 2016;27(2):e36. [8] Cauldwell M, Chappell LC, Murtagh G, Bewley S. Learning about maternal death and grief in the profession: a pilot qualitative study. Acta Obstet Gynecol Scand 2015;94(12):1346–53. [9] Leape LL. Error in Medicine. JAMA 1994;272(23):1851–8. [10] Santomauro CM, Kalkman CJ, Dekker S. Second victims, organizational resilience and the role of hospital administration. J Hos Admin 2014;3(5):95– 104. [11] Wu AW. Medical error: the second victim: The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726–7. [12] Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. The Joint Commission Journal on Quality and Patient Safety 2010;36(5):233–40. [13] Hilfiker D. Facing our mistakes. N Engl J Med. 1984;310(2):118–22. [14] Mira JJ, Carrillo I, Lorenzo S, et al. The aftermath of adverse events in Spanish primary care and hospital health professionals. BMC Health Services Research 2015;15:151–60. [15] Harrison R, Lawton R, Stewart K. Doctors experiences of adverse events in secondary care: the professional and personal impact. Clin Med 2014;14:585– 90. [16] 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 professionals’ psychological well-being. Qual Saf Health Care 2010;19:e43. [17] Stewart K, Lawton R, Harrison R. Supporting second victims is a system-wide responsibility. BMJ 2015;350:h2341. [18] Conway J, Federico F, Stewart K, Campbell M. Respectful management of serious clinical adverse events. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2010. [19] M. Higgins. The second victim in modern healthcare. BMJ Blogs. Accessed on March 6th 2017 from http://blogs.bmj.com/bmj/2016/08/22/mary-higginsthe-second-victim-in-modern-healthcare/. [20] Plunkett A. Presentation at the Social Media and Critical Care Conference. Accessed on March 7th from http://learningfromexcellence.com/videos/. [21] Higgins M. The echoes of past events. Accessed on March 6th 2017 fromhttp:// blogs.bmj.com/bmj/2017/03/02/how-the-ghost-of-patients-past-have-adeeper-impact-than-we-may-think/. [22] Lander LI, Connor JA, Shah RK, Kentala E, Healy GB, Roberson DW. Otolaryngologists’ responses to errors and adverse events. Laryngoscope 2006;116:1114–20. [23] Wolf ZR, Serembus JF, Smetzer J, Cohen H, Cohen M. Responses and concerns of healthcare providers to medication errors. Clinical Nurse Specialist 2000;14:278–87. [24] Engel KG, Rosenthal M, Sutcliffe KM. Residents’ responses to medical error: Coping, learning, and change. Academic Medicine 2006 2006;81:86–93. [25] Marmar CR, Weiss DS, Metzler TJ, Ronfeldt HM, Foreman C. Stress responses of emergency services personnel to the Loma Prieta earthquake Interstate 880 freeway collapse and control traumatic incidents. J Trauma Stress 1996;9:63– 85. [26] Kaldjian LC, Forman-Hoffman VL, Jones EW, Wu BJ, Levi BH, Rosenthal GE. Do faculty and resident physicians discuss their medical errors? Journal of Medical Ethics 2008;34:717–22. [27] Muller D, Ornstein K. Perceptions of and attitudes towards medical errors among medical trainees. Medical Education 2007;41:645–52. [28] West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy. JAMA. 2006;296(9):1071–8. [29] Chen PW. Doctor and patient: when doctors make mistakes. New York Times; 2017 July 9, 2009. Accessed March 6th 2017 from:http://nytimes.com/2009/ 07/09/health/09chen.html..
16
B. Coughlan et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 213 (2017) 11–16
[30] Kronman AC, Paasche-Orlow M, Orlander JD. Factors associated with disclosure of medical errors by housestaff. BMJ Qual Saf 2012;21(4):271–8. [31] Gallagher TH, Waterman AD, Ebers AG, et al. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA 2003;289:1001–7. [32] Coffey M, Thomson K, Tallet S, Matlow A. Pediatric residents decision-making around disclosing and reporting adverse events: the importance of social context. Acad Med 2010;85(10):1619–25. [33] Martinez W, Lo B. Medical students’ experiences with medical errors: An analysis of medical student essays. Medical Education 2008;42:733–41. [34] Leinweber J, Creedy DK, Rowe H, Gamble J. Responses to birth trauma and prevalence of posttraumatic stress among Australian midwives. Women Birth 2016(July), doi:http://dx.doi.org/10.1016/j.wombi.2016.06.006. [35] Wahlberg A, Saches A, Johannesson K, et al. Post-traumatic stress symptoms in Swedish obstetricians and midwives after severe obstetric events: a cross sectional retrospective survey. BJOG 2016, doi:http://dx.doi.org/10.1111/14710528.14259. [36] Schrøder K, Larsen PV, Jørgensen JS, Hjelmborg JV, Lamont RF, Hvidt NC. Psychosocial health and well-being among obstetricians and midwives involved in traumatic childbirth. Midwifery 2016;41:45–53. [37] Nuzem D, Meaney S, O’Donoghue K, Morris H. The spiritual and theological issues raised by stillbirth for healthcare chaplins. J Pastoral Care Counsel 2015;69(3):163–70. [38] Bell SK, Moorman DW, Delbanco T. Improving the patient, family, and clinician experience after harmful events: The “when things go wrong” curriculum. Academic Medicine 2010;85:1010–7. [39] Clemmer J. Customer satisfaction is a reflection of employee satisfaction. Accessed March 6th 2017 from: http://www.clemmergroup.com/articles/ customer-satisfaction-reflection-employee-satisfaction/. [40] Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf. 2011;21(April (4))267– 70, doi:http://dx.doi.org/10.1136/bmjqs-2011-000605 Epub 2012 Jan 2. [41] Kelly N, Blake S, Plunkett A. Learning from excellence in healthcare: a new approach to incident reporting. Arch Dis Child 2016;101(9):788–91. [42] Denham,. C.R TRUST: the 5 rights of the second victim. Journal of Patient Safety 2007;3(2):107–19. [43] Vaithilingam N, Jain S, Davies D. Helping the helpers: debriefing following an adverse incident. The Obstetrician and Gynaecologist 2008;10:251–6. [44] Mitchell JT, Everly Jr. GS. Critical Incident Stress Debriefing: (CISD). Ellicott City Md: Chevron Publishing Co; 1993.
[45] Birks Y, Harrison R, Bosanquet K, et al. An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review and qualitative exploration. Health Serv and Delivery Research 2016;2:20. [46] Open Disclosure - National Guidelines. Communicating with service users and their families following adverse events in healthcare. HSE, Dublin, 2013. [47] van Pelt F. Peer support: healthcare professionals supporting each other after adverse medical events. Qual Saf Health Care 2008;17:249–52. [48] Wu AW, Folkman S, McPhee SJ, Lo B. How house officers cope with their mistakes. Western Journal of Medicine 1993;159:565–9. [49] Christensen JF, Levinson W, Dunn PM. The heart of darkness: The impact of perceived mistakes on physicians. J Gen Int Med 1993;7:424–31. [50] Chard R. How perioperative nurses define, attribute causes of, and react to intraoperative nursing errors. AORN Journal 2010;91:132–45. [51] Meurier CE, Vincent CA, Parmar DG. Nurses’ responses to severity dependent errors. Journal of Advanced Nursing 1993;27:349–54. [52] Ofri D. Ashamed to admit it: owning up to medical error. Health Aff (Millwood). 2010;29(8):1549–51. [53] Weiss P. Medical Errors and the second victim. The female patient 2011;36:29– 32. [54] Resilient Health Care. In: Hollnagel E, Braithwaite J, Wears RL, editors. Farnham, UK: Ashgate; 2013. [55] Pettker CM, Funai EF. Getting it right when things go wrong. JAMA 2010;303 (10):856–977. [56] Edrees H, Connors C, Paine L, Norvell M, Taylor H, Wu AW. Implementing the RISE second victim support programme at the Johns Hopkins Hospital. a case study 2016;6(September (9)):e011708. [57] Medically Induced Trauma Support System. Accessed on March 6th 2017 at http://www.mitss.org. [58] ASSIST-ME model: supporting staff following an adverse event. Accessed on March 6th 2017 at: http://www.hse.ie/eng/about/Who/qualityandpatientsafety/nau/Open_Disclosure/opendiscFiles/bookletSuppStaffadverseevent.pdf. [59] Seys D, Wu A, Van Gerven E, Vleugels A, Euwema M, Panella M, Scott S, Conway J, Sermeus W, Vanhaecht K. Health Care Professionals as Second Victims after Adverse Events: A Systematic Review. Evaluation & the Health Professions 2016;36(2):135–62. [60] Cooperrider DL, Whitney D. A positive revolution in change: appreciative inquiry. Public Adm Public Policy 2001;87:611–30.