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After an Adverse Event, Staff Needs Support

Tami Swartz, March 28, 2013

This article appears in the February 2013 edition of Patient Safety Monitor.

Mistakes happen. Many times when mistakes happen in hospitals, the hospital's system a nd process design has at least in part failed a frontline provider. How much of a human error is truly the fault of the hospital could probably be under debate well after the incident. However, no matter what is eventually determined, there is usually at least one person who works for the hospital who will suffer being the second victim.

The first victim, of course, is the patient and family ­affected by a patient care mistake. Sometimes these mistakes are minor and sometimes they are fatal. Much has been researched about patient safety, and in recent years, attention has also turned toward these second victims-providers involved in the ­adverse event, who are also the hospital's responsibility. Evidence suggests these second victims, if not given the correct ­support, can contribute to further patient safety problems; and, of course, each person in a work system affects culture.

What happens after an event is critical to the ­future of a hospital's culture of safety. Not only could an ­unsupported second victim suffering intense emotional distress be more likely to make mistakes, but how this second victim is treated will be noted by other ­providers and staff who contribute to patient care.

If this person is penalized, punished, or simply ignored, nurses, housekeepers, physicians, etc., might think twice before reporting their own or someone else's next ­mistake. They might lose faith in leadership and lose desire to participate in quality initiatives. The idea of a culture of safety is to work together to avoid mistakes, but it's important that quality ­directors, nurse managers, and leadership understand that a strong culture means addressing an event head-on.

More than a decade of research on second victims

A new literature review has identified some interesting evidence on second victims and the effect second victims have on hospital culture.

Although evidence found that being part of an adverse event can make a provider more prone to future errors, a hospital can avert that possibility by providing emotional support.

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