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Found 37 results
  1. Content Article
    When healthcare students witness, engage in, or are involved in an adverse event, it often leads to a second victim experience, impacting their mental well-being and influencing their future professional practice. This study aimed to describe the efforts, methods, and outcomes of interventions to help students in healthcare disciplines cope with the emotional experience of being involved in or witnessing a mistake causing harm to a patient during their clerkships or training.
  2. News Article
    Alice and Lewis Jones were forced to watch their 18-month-old baby die in front of them after a failure by a scandal-hit NHS trust left him with a “catastrophic brain injury” following his birth. Their son Ronnie was one of hundreds of babies who have died following errors by Shrewsbury and Telford Hospital, where the largest NHS maternity scandal to date was previously uncovered by The Independent. Two years later, Mr and Mrs Jones are calling for the Supreme Court to overturn a controversial decision in February which ruled bereaved relatives could not claim compensation over the psychological impact of seeing a loved one die, even if it was caused by medical negligence. It comes after the trust admitted to failings in a letter to the parents’ lawyers. Ronnie’s birth in 2020 fell outside of the Ockenden review and his parents have warned it showed failures were still occurring despite warnings made during the inquiry. Within the Ockenden inquiry, multiple cases of staff failing to recognise and act upon CTG training were found, and the final report recommended all hospitals have systems to ensure staff are trained and up to date in CTG and emergency skills. The report also said the NHS should make CTG training mandatory and that clinicians must not work in labour wards or provide childbirth care without it. A CTG measures a baby’s heart and monitors conditions in the uterus and is an important measure before birth and during labour to observe the baby for any signs of distress. Ms Jones said: “We knew about the Ockenden review, but everything at Telford was new and so I think we just assumed that lessons had been learned, the same thing wouldn’t happen to us.” Ronnie’s parents are campaigning to reverse the Supreme Court which ruled that “secondary victims” – including parents who are not directly harmed by the birth – are not eligible to bring claims for psychiatric injury following medical negligence. Read full story Source: The Independent, 14 March 2024
  3. Content Article
    A common theme of recent international inquiries is that well intentioned investigations often make things worse. Harm is compounded when we fail to listen, validate and respond to the rights and needs of all the people involved. When lengthy processes do not result in meaningful action, suffering can be exacerbated and result in further damage to wellbeing, relationships, and trust. At its worst, compounded harm produces undesirable outcomes such as a community believing an essential service is unsafe, or a clinician leaving their profession. In considering how best to respond, it is important to remember that health systems are comprised of people and relationships, as well as rules and processes. Once we think about safety as a human and relational approach, rather than one that only seeks to lessen risk and enforce regulation, we can consider how to best proceed. Whether an act is intentional or not, a dignifying approach involves working together to repair the harm involved. Restorative responses are ideal for this purpose, as Jo Wailling, Co-chair of the National Collaborative for Restorative Initiatives in Health Aotearoa New Zealand, explains in this blog on the Patient Safety Commissioner website.
  4. Content Article
    A second victim is a healthcare worker who is traumatised by an unexpected adverse patient case, therapeutic mistake, or patient-associated injury that has not been anticipated. Often, the second victim experiences direct guilt for the harm caused to the patients. Healthcare organisations are often unaware of the emotional toll that adverse events can have on healthcare providers (HCPs) who can be harmed by the same incidents that harm their patients. This study aims to examine the second victim phenomenon among healthcare providers at Al-Ahsa hospitals, its prevalence, symptoms, associated factors, and support strategies.
  5. Content Article
    Patient safety incidents, including medical errors and adverse events, frequently occur in intensive care units, leading to a significant psychological burden on healthcare professionals. This burden results in second victim syndrome, which impacts the psychological and psychosomatic wellbeing of these staff members. This systematic review and meta-analysis aimed to examine the occurrence of second victim syndrome among intensive care unit healthcare workers, including the types, prevalence, risk factors and recovery time associated with the condition.
  6. Content Article
    The harsh reality of surgery often involves grappling with the distressing and emotionally taxing aspects of human suffering that many people outside of healthcare never witness. When complications occur, surgeons feel the weight of their responsibility and are often alone to ruminate with negative thoughts of self-doubt, sometimes leading to anxiety and depression. This article in The American Journal of Surgery examines existing literature on Second Victim Syndrome (SVS) specifically focusing on prevalence among surgeons and factors related to different responses. The authors identify women and junior surgeons at particularly high risk of SVS and peer support as a preferred method of coping but an overall lack of institutional support highlighting the need for ongoing, open conversations about the topic of surgeon well-being.
  7. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Rob talks to us about his passion for using human factors to improve safety in emergency departments, how allowing doctors to choose their own shifts can make staffing safer and how better integrating technology could help doctors diagnose and treat patients more safely and effectively.
  8. Content Article
    This video from the Irish Health Services Executive (HSE) tells the story of Barry, a paediatric nurse who made a medication error when treating a critically ill baby. Barry describes how the incident and the management response to it affected his mental health and confidence over a long period of time. He also describes how he had to fight to ensure the family were told the full story of what had happened, and the positive relationship he developed with the baby's mother as a result. The baby received the treatment they needed and recovered well.
  9. Content Article
    This document by the Joint Commission provides an overview of the issues faced by healthcare workers who are negatively affected by their involvement in a patient safety incident—second victims. It highlights the prevalence of second victims, summarises the key problems they face and outlines recommendations to ensure staff receive adequate support from healthcare organisations when they are involved in an incident.
  10. Content Article
    Second victims are healthcare workers who experience emotional distress following patient adverse events. This mixed method study in BMJ Open looks at how the RISE (Resilience In Stressful Events) programme was developed at the Johns Hopkins Hospital to provide this support. It examined: developing the RISE programme recruiting and training peer responders pilot launch in the Department of Paediatrics hospital-wide implementation.
  11. Content Article
    Every day, healthcare professionals face the risk of traumatic events — such as an unexpected death, a medical error, or an unplanned transfer to the ICU. Yet few hospitals have programmes to support “second victims.” Too often, these employees experience self-doubt, burnout and other problems that cause personal anguish and hinder their ability to deliver safe, compassionate care. The Caring for the Caregiver programme from John Hopkins Medicine in the USA guides hospitals to set up peer-responder programmes that deliver “psychological first aid and emotional support” to health care professionals following difficult events. Modelled on the Resilience in Stressful Events (RISE) team at The Johns Hopkins Hospital, the programme prepares employees to provide skilled, nonjudgmental and confidential support to individuals and groups.
  12. Content Article
    Medical errors, especially those resulting in patient harm, have a negative psychological impact on patients and healthcare workers. Healing may be promoted if both parties are able to work together and explore the effect and outcome of the event from each of their perspectives. There is little existing research in this area, even though this has the potential to improve patient safety and wellness for both healthcare workers and patients. Using a patient-oriented research approach, this study in BMJ Open Quality examined the potential for patients and healthcare workers to heal together after harm from a medical error. The study's findings suggest that, after a medical error causing harm, both patients and healthcare workers have feelings of empathy and respect towards each other that often goes unrecognised. Barriers to communication for patients were related to their perception that healthcare workers did not care about them, showed no remorse or did not admit to the error. For healthcare workers, communication barriers were related to feelings of blame or shame, and fear of professional and legal consequences. Patients reported needing open and transparent communications to help them heal, and healthcare workers required leadership and peer support, including training and space to talk about the event.
  13. Content Article
    Medication errors are the most common adverse event in hospitals and have significant economic and health consequences. This white paper developed by the European Collaborative Action on Medication Errors and Traceability (ECAMET) Alliance collects the results of a pan-European survey on medication errors. It includes 25 reports comprising 13 country reports in English, eight translations in other languages, a private hospitals report, specialised oncology and ICU reports and one consolidated report. It makes several recommendations to reduce medication errors in hospitals and highlights the need to: establish a culture of safety. create strategies to improve communication. raise awareness and organise regular multi-disciplinary training meetings. systematically use accreditation/certification systems. introduce technological tools.
  14. Content Article
    Second victims are healthcare providers involved in an unexpected adverse event, medical error or injury affecting a patient, who become victims in the sense they are traumatised by it. The purpose of the 'European Researchers' Network Working on Second Victims' is to Introduce an open dialogue among stakeholders about the theoretical conceptualisation and practical consequences of the second victims’ phenomenon based on a cross-national collaboration that integrates different disciplines and approaches. It facilitates discussion and share scientific knowledge, perspectives, and best practices concerning the consequences of adverse events in the healthcare workforce and to implement joint efforts to tackle with the second victims’ phenomenon.
  15. Content Article
    This study by Sexton et al. was performed to determine whether health care worker (HCW) assessments of good institutional support for second victims were associated with institutional safety culture and workforce well-being. They found that perceived institutional support for second victims was associated with a better safety culture and lower emotional exhaustion. Investment in programmes to support second victims may improve overall safety culture and HCW well-being.
  16. Content Article
    Patient safety incidents can have significant effects on both patients and health professionals, including emotional distress and depression. This, published in British Journal of Surgery (BJS) Open, study explores the personal and professional impacts of surgical incidents on operating theatre staff. This study, published in BJS Open, involved 45 face-to-face interviews, with participants including surgeons, anaesthetists, scrub nurses, ODPs and healthcare assistants. The authors state that the results indicate that more support is needed for operating theatre staff involved in surgical incidents. They also suggest that there needs to be greater transparency and better information during the investigation of such incidents for staff.
  17. Content Article
    This systematic review, published in the International Journal of Environmental Research and Public Health, looks at different support resources in healthcare organisation that are available to healthcare professionals who have been involved in a patient safety incident. The authors identify a range of challenges to the implementation of these, including persistent blame culture, limited awareness of program availability, and lack of financial resources.
  18. Community Post
    Following the posting of the recent anonymous blog by a brave nurse - a discussion was started on Twitter about the aspect of accountability, duty of candour mixed with a no blame culture. If there has been a drug error: The person who did the error needs to feel secure in the knowledge that there is a no blame culture, otherwise they may not report it in the first place. The patient needs to be told that they has been an error with their care The person who did the error needs to be held to account So, can these three points coexist or are we wanting the impossible?
  19. Content Article
    In this blog, nurse Carol Menashy describes her experience making an error in theatre fifteen years ago, and the personal blame she faced in the way the incident was dealt with at the time. She talks about how a SEIPS (Systems Engineering Initiative for Patient Safety) framework can transform how adverse incidents are dealt with, allowing healthcare teams to learn together and use incidents to help make positive changes towards patient safety. She describes the progress that has been made towards organisational accountability and systems thinking over the past fifteen years, and talks about the importance of staff support to allow for healing from adverse events.
  20. Content Article
    Reducing stress is an organisational imperative since workplace pressures continue to be one of the main causes of short and long-term absence. According to research undertaken by CIPD based on responses from 804 organisations, 79% of respondents report some stress-related absence in their organisation over the last year. Healthcare settings have an even higher rate of absence due to stress, yet there is reason to be optimistic that this could start to change when a new policy from NHS England is implemented, which recommends the use of After Action Review (AAR). In this blog, Judy Walker explains how AARs can play a key role in reducing stress for those who have been involved in clinical incidents.  
  21. Content Article
    Restorative justice brings those harmed by crime or conflict and those responsible for causing their harm into contact with each other. In healthcare, this can involve bringing together patients and families of patients who have suffered avoidable harm, and the healthcare professionals who may be responsible for this harm. The aim is to enable everyone affected by an incident to play a part in helping to set right the hurt or injury caused, and hopefully find a positive way forward. This blog outlines the content of a lecture given to staff at the Healthcare Safety Investigation Branch (HSIB) by Jo Wailling, Senior Research Fellow at Te Herenga Waka - Victoria University of Wellington, New Zealand, who is a globally-renowned expert in restorative practice and justice in healthcare. It covers Jo's experience of co-designing and evaluating New Zealand's innovative restorative response to surgical mesh harm, practical examples for patient safety investigations and how HSIB is going to integrate restorative justice principles in its future investigations.
  22. Content Article
    Martin Anderson, author of the Human Factors 101 blog, looks at the case of US nurse RaDonda Vaught, who was found guilty of criminally negligent homicide and abuse of an impaired adult following a medication error that led to a patient death in 2017. He provides a timeline of the events that occurred in the run up to the criminal trial and highlights concerns that the case will set a precedent in bringing criminal charges against nurses when there is no intent to harm a patient. He then looks at the system factors that may have contributed to the medication error, asking a number of questions about the circumstances under which Vaught made the error. The blog goes on to outline the serious impact the case could have on healthcare professionals' willingness to report errors, take on complex cases and use innovative treatments—it may even put people off taking on a career in the healthcare sector in the first place.
  23. Content Article
    The aim of this study from Choi et al. was to investigate the scope and severity of the second victim problem among nurses in South Korea by examining the experiences and effects of patient safety incidents (PSIs) on them. The study found a considerable number of nurses experienced psychological difficulties due to PSIs at levels that could interfere with their work. The effect of PSIs on nurses with direct experience of PSIs was greater compared with those with indirect experience. There need to be psychological support programmes for nurses to alleviate the negative effects of PSIs.
  24. Content Article
    The Patient Safety Learning hub has provided the vehicle through which I’ve shared my personal journey as I sought to establish and embed a second victim support initiative at the trust where I worked until my recent retirement.  Four years ago SISOS was set up to ensure that colleagues affected by safety incidents received emotional support as soon as possible. A lot of lessons have been learned along the way and positive actions taken. These are my personal thoughts.
  25. Content Article
    When patients experience unexpected events, some health professionals become “second victims”. These care givers feel as though they have failed the patient, second guessing clinical skills, knowledge base and career choice. Although some information exists, a complete understanding of this phenomenon is essential to design and test supportive interventions that achieve a healthy recovery. Scott et al., in a paper published in BMJ Quality & Safety, report interview findings with 31 second victims.
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