Second victims in health care: current perspectives

References

• Wienke A. Errors and pitfalls: briefing and accusation of medical malpractice - the second victim. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2013;12:Doc10.
   PubMedGoogle Scholar
• Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726–727. doi:10.1136/bmj.320.7237.726
   PubMed Web of Science ®Google Scholar
• Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care. 2009;18(5):325–330. doi:10.1136/qshc.2009.032870
   PubMedGoogle Scholar
• Denham C. TRUST: the 5 rights of the second victim. J Patient Saf. 2007;3(2):107–119. doi:10.1097/01.jps.0000236917.02321.fd
   Google Scholar
• Wu AW, Shapiro J, Harrison R, et al. The impact of adverse events on clinicians: what’s in a name? J Patient Saf. 2017. doi:10.1097/PTS.0000000000000256
   Web of Science ®Google Scholar
• Clarkson MD, Haskell H, Hemmelgarn C, Skolnik PJ. Abandon the term “second victim”. BMJ. 2019;364:l1233. doi:10.1136/bmj.l42
   Web of Science ®Google Scholar
• Tumelty ME. The second victim: a contested term? J Patient Saf. 2018. doi:10.1097/PTS.0000000000000558
   Web of Science ®Google Scholar
• Gomez-Duran EL, Tolchinsky G, Martin-Fumado C, Arimany-Manso J. Neglecting the “second victim” will not help harmed patients or improve patient safety. BMJ. 2019;365:l2167. doi:10.1136/bmj.l2167
   Web of Science ®Google Scholar
• Seys D, Wu AW, Van Gerven E, et al. Health care professionals as second victims after adverse events: a systematic review. Eval Health Prof. 2013;36(2):135–162. doi:10.1177/0163278712458918
   PubMed Web of Science ®Google Scholar
• Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007;33(8):467–476.
   PubMedGoogle Scholar
• Edrees HH, Paine LA, Feroli ER, Wu AW. Health care workers as second victims of medical errors. Pol Arch Med Wewn. 2011;121(4):101–108.
   Web of Science ®Google Scholar
• Han K, Bohnen JD, Peponis T, et al. The Surgeon as the second victim? Results of the boston intraoperative adverse events surgeons’ attitude (BISA) study. J Am Coll Surg. 2017;224(6):1048–1056. doi:10.1016/j.jamcollsurg.2016.12.039
   Web of Science ®Google Scholar
• Pettker CM. Systematic approaches to adverse events in obstetrics, Part II: event analysis and response. Semin Perinatol. 2017;41(3):156–160. doi:10.1053/j.semperi.2017.03.004
   Web of Science ®Google Scholar
• Schroder K, Larsen PV, Jorgensen 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. doi:10.1016/j.midw.2016.07.013
   Web of Science ®Google Scholar
• Rodziewicz TL, Hipskind JE. Medical Error Prevention. Treasure Island (FL): StatPearls; 2018.
   Google Scholar
• Treiber LA, Jones JH. Making an infusion error: the second victims of infusion therapy-related medication errors. J Infus Nurs. 2018;41(3):156–163. doi:10.1097/NAN.0000000000000273
   PubMed Web of Science ®Google Scholar
• Grissinger M. Too many abandon the “second victims” of medical errors. P T. 2014;39(9):591–592.
   Google Scholar
• Cabilan CJ, Kynoch K. Experiences of and support for nurses as second victims of adverse nursing errors: a qualitative systematic review. JBI Database Syst Rev Implement Rep. 2017;15(9):2333–2364. doi:10.11124/JBISRIR-2016-003254
   Google Scholar
• Rassin M, Kanti T, Silner D. Chronology of medication errors by nurses: accumulation of stresses and PTSD symptoms. Issues Ment Health Nurs. 2005;26(8):873–886. doi:10.1080/01612840500184566
   PubMedGoogle Scholar
• Mayo AM, Duncan D. Nurse perceptions of medication errors: what we need to know for patient safety. J Nurs Care Qual. 2004;19(3):209–217.
   PubMed Web of Science ®Google Scholar
• Kronman AC, Paasche-Orlow M, Orlander JD. Factors associated with disclosure of medical errors by housestaff. BMJ Qual Saf. 2012;21(4):271–278. doi:10.1136/bmjqs-2011-000084
   PubMed Web of Science ®Google Scholar
• Wolf ZR. Stress management in response to practice errors: critical events in professional practice. PA-PSRS Patient Saf Advisory. 2005;2:1–4.
   Google Scholar
• Schwappach DL, Boluarte TA. The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability. Swiss Med Wkly. 2009;139(1–2):9–15. doi:/aop/smw-aop12417
   PubMed Web of Science ®Google Scholar
• Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf. 2012;21(4):267–270. doi:10.1136/bmjqs-2011-000605
   Web of Science ®Google Scholar
• Baas MAM, Scheepstra KWF, Stramrood CAI, Evers R, Dijksman LM, van Pampus MG. Work-related adverse events leaving their mark: a cross-sectional study among Dutch gynecologists. BMC Psychiatry. 2018;18(1):73. doi:10.1186/s12888-018-1659-1
   Web of Science ®Google Scholar
• Burlison JD, Scott SD, Browne EK, Thompson SG, Hoffman JM. The second victim experience and support tool: validation of an organizational resource for assessing second victim effects and the quality of support resources. J Patient Saf. 2017;13(2):93–102. doi:10.1097/PTS.0000000000000129
   PubMed Web of Science ®Google Scholar
• Chung AS, Smart J, Zdradzinski M, et al. Educator toolkits on second victim syndrome, mindfulness and meditation, and positive psychology: the 2017 resident wellness consensus summit. West J Emerg Med. 2018;19(2):327–331. doi:10.5811/cpcem.2017.11.36179
   Web of Science ®Google Scholar
• Hauk L. Understanding the second victim recovery process. Aorn J. 2018;107(6):P4.
   Web of Science ®Google Scholar
• Robertson JJ, Long B. Suffering in silence: medical error and its impact on health care providers. J Emerg Med. 2018;54(4):402–409. doi:10.1016/j.jemermed.2017.12.001
   Web of Science ®Google Scholar
• Pellino IM, Pellino G. Consequences of defensive medicine, second victims, and clinical-judicial syndrome on surgeons’ medical practice and on health service. Updates Surg. 2015;67(4):331–337. doi:10.1007/s13304-015-0338-8
   PubMed Web of Science ®Google Scholar
• Santoro E. Clinical-judicial syndrome: how a doctor becomes a patient through general indifference. Updates Surg. 2014;66(3):173–175. doi:10.1007/s13304-014-0264-1
   Google Scholar
• Ozeke O, Aras S, Baser K, et al. Defensive medicine due to different fears by patients and physicians in geriatric atrial fibrillation patients and second victim syndrome. Int J Cardiol. 2016;212:251–252. doi:10.1016/j.ijcard.2016.03.093
   PubMed Web of Science ®Google Scholar
• Kowey PR. How much has malpractice litigation altered the care of cardiac rhythm patients? J Cardiovasc Electrophysiol. 2011;22(4):488–489. doi:10.1111/j.1540-8167.2011.02019.x
   Web of Science ®Google Scholar
• Vento S, Cainelli F, Vallone A. Defensive medicine: it is time to finally slow down an epidemic. World J Clin Cases. 2018;6(11):406–409. doi:10.12998/wjcc.v6.i11.406
   PubMed Web of Science ®Google Scholar
• Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356(26):2713–2719. doi:10.1056/NEJMra070568
   PubMed Web of Science ®Google Scholar
• Edrees HH, Morlock L, Wu AW. Do hospitals support second victims? Collective insights from patient safety leaders in Maryland. Jt Comm J Qual Patient Saf. 2017;43(9):471–483. doi:10.1016/j.jcjq.2017.01.008
   Web of Science ®Google Scholar
• Edrees HH, Wu AW. Does one size fit all? Assessing the need for organizational second victim support programs. J Patient Saf. 2017. doi:10.1097/PTS.0000000000000321
   Web of Science ®Google Scholar
• Seys D, Scott S, Wu A, et al. Supporting involved health care professionals (second victims) following an adverse health event: a literature review. Int J Nurs Stud. 2013;50(5):678–687. doi:10.1016/j.ijnurstu.2012.07.006
   PubMed Web of Science ®Google Scholar
• Reason J. Human error: models and management. BMJ. 2000;320(7237):768–770. doi:10.1136/bmj.320.7237.768
   PubMed Web of Science ®Google Scholar
• Chervenak FA, McCullough LB. The moral foundation of medical leadership: the professional virtues of the physician as fiduciary of the patient. Am J Obstet Gynecol. 2001;184(5):875–879; discussion 879–880. doi:10.1067/mob.2001.113854
   Web of Science ®Google Scholar
• Martens J, Van Gerven E, Lannoy K, et al. Serious reportable events within the inpatient mental health care: impact on physicians and nurses. Rev Calid Asist. 2016;31(Suppl 2):26–33. doi:10.1016/j.cali.2016.04.004
   Google Scholar
• Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010;36(5):233–240.
   PubMedGoogle Scholar
• Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265(16):2089–2094.
   PubMed Web of Science ®Google Scholar
• 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. BMJ Open. 2016;6(9):e011708. doi:10.1136/bmjopen-2016-011708
   PubMed Web of Science ®Google Scholar
• Mira JJ, Lorenzo S, Carrillo I, et al. Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations. Int J Qual Health Care. 2017;29(4):450–460. doi:10.1093/intqhc/mzx056
   Web of Science ®Google Scholar
• Rabow MW, McPhee SJ. Beyond breaking bad news: how to help patients who suffer. West J Med. 1999;171(4):260–263.
   PubMedGoogle Scholar
• Shor S, Tal O, Maymon R. The second victim: treating the health care providers. Harefuah. 2017;156(1):38–40.
   Google Scholar
• Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139. doi:10.1136/bmj.i2996
   PubMed Web of Science ®Google Scholar
• Reason J. James Reason: patient safety, human error, and Swiss cheese. Interview by Karolina Peltomaa and Duncan Neuhauser. Qual Manag Health Care. 2012;21(1):59–63. doi:10.1097/QMH.0b013e3182418294
   Google Scholar
• McLennan S, Rich LE, Truog RD. Apologies in medicine: legal protection is not enough. CMAJ. 2015;187(5):E156–159. doi:10.1503/cmaj.131860
   Web of Science ®Google Scholar
• Crigger NJ. Always having to say you’re sorry: an ethical response to making mistakes in professional practice. Nurs Ethics. 2004;11(6):568–576. doi:10.1191/0969733004ne739oa
   PubMed Web of Science ®Google Scholar
• Lee TH. A broader concept of medical errors. N Engl J Med. 2002;347(24):1965–1967. doi:10.1056/NEJMe020149
   Web of Science ®Google Scholar
• Hayward RA, Asch SM, Hogan MM, Hofer TP, Kerr EA. Sins of omission: getting too little medical care may be the greatest threat to patient safety. J Gen Intern Med. 2005;20(8):686–691. doi:10.1111/j.1525-1497.2005.0152.x
   PubMed Web of Science ®Google Scholar
• Downing L, Potter RL. Heartland regional medical center makes a “fitting response” to medical mistakes. Bioethics Forum. 2001;17(2):12–18.
   Google Scholar
• Leape LL. Error in medicine. JAMA. 1994;272(23):1851–1857.
   PubMed Web of Science ®Google Scholar
• Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med. 1997;12(12):770–775. doi:10.1046/j.1525-1497.1997.07163.x
   PubMed Web of Science ®Google Scholar
• EG H. How should ethics consultants respond when care providers have made or may have made a mistake? Beware of ethical flypaper. In: Rubin SB, Zoloth L, editors. Margin of Error the Ethics of Mistakes in the Practice of Medicine. Hagerstown (MD): University Publishing Group; 2000:165–181.
   Google Scholar
• Boysen PG 2nd. Just culture: a foundation for balanced accountability and patient safety. Ochsner J Fall. 2013;13(3):400–406.
   PubMedGoogle Scholar
• Marx. D. Patient Safety and the Just Culture: A Primer for Health Care Executives. New York (NY): Trustees of Columbia University; 2001.
   Google Scholar
• Hare. RM. Moral Thinking: Its Levels, Method, and Point. Oxford: Clarendon Press; 1991.
   Google Scholar
• Mastroianni AC, Mello MM, Sommer S, Hardy M, Gallagher TH. The flaws in state ‘apology’ and ‘disclosure’ laws dilute their intended impact on malpractice suits. Health Aff (Millwood). 2010;29(9):1611–1619. doi:10.1377/hlthaff.2009.0134
   Web of Science ®Google Scholar
• Lee MJ. On patient safety: do you say “i’m sorry” to patients? Clin Orthop Relat Res. 2016;474(11):2359–2361. doi:10.1007/s11999-016-5025-7
   Web of Science ®Google Scholar
• Teninbaum GH. Saying ‘sorry’ isn’t enough. Health Aff (Millwood). 2010;29(11):2127. doi:10.1377/hlthaff.2010.0992
   Web of Science ®Google Scholar
• Wu AW, Huang IC, Stokes S, Pronovost PJ. Disclosing medical errors to patients: it’s not what you say, it’s what they hear. J Gen Intern Med. 2009;24(9):1012–1017. doi:10.1007/s11606-009-1044-3
   PubMed Web of Science ®Google Scholar
• Mazor KM, Reed GW, Yood RA, Fischer MA, Baril J, Gurwitz JH. Disclosure of medical errors: what factors influence how patients respond? J Gen Intern Med. 2006;21(7):704–710. doi:10.1111/j.1525-1497.2006.00465.x
   Web of Science ®Google Scholar
• Anonymous. Holding out for an apology. BMJ. 2018;363:k3033. doi:10.1136/bmj.k4029
   Web of Science ®Google Scholar
• Kohler JE. I’m a doctor. Can I help? Ann Fam Med. 2015;13(5):490–491. doi:10.1370/afm.1823
   Web of Science ®Google Scholar
• Wu AW, Boyle DJ, Wallace G, Mazor KM. Disclosure of adverse events in the United States and Canada: an update, and a proposed framework for improvement. J Public Health Res. 2013;2(3):e32. doi:10.4081/jphr.2013.e32
   Google Scholar
• H M, Haughn Z. Full disclosure: how to apologize for medical errors. Pract Neurol. 2011;25:25–30.
   Google Scholar
• Mira JJ, Carrillo I, Guilabert M, et al. The second victim phenomenon after a clinical error: the design and evaluation of a website to reduce caregivers’ emotional responses after a clinical error. J Med Internet Res. 2017;19(6):e203. doi:10.2196/jmir.7840
   Web of Science ®Google Scholar
• Conway J, Stewart K, Campbell MJ Respectful management of serious clinical adverse events. IHI Innovation Series white paper. Cambridge Massachusetts: Institute for Healthcare Improvement. 2010.
   Google Scholar
• VandeKieft GK. Breaking bad news. Am Fam Physician. 2001;64(12):1975–1978.
   PubMed Web of Science ®Google Scholar
• Fulmer T, Escobedo M, Berman A, Koren MJ, Hernandez S, Hult A. Physicians’ views on advance care planning and end-of-life care conversations. J Am Geriatr Soc. 2018;66(6):1201–1205. doi:10.1111/jgs.15374
   PubMed Web of Science ®Google Scholar
• Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302–311. doi:10.1634/theoncologist.5-4-302
   PubMedGoogle Scholar
• Sanford DE, Fleming DA. We meant no harm, yet we made a mistake; why not apologize for it? A student’s view. HEC Forum. 2010;22(2):159–169. doi:10.1007/s10730-010-9131-8
   Google Scholar
• Back AL, Fromme EK, Meier DE. Training clinicians with communication skills needed to match medical treatments to patient values. J Am Geriatr Soc. 2019;67(S2):S435–S441. doi:10.1111/jgs.15709
   PubMed Web of Science ®Google Scholar
• Krizek TJ. Surgical error: ethical issues of adverse events. Arch Surg. 2000;135(11):1359–1366. doi:10.1001/archsurg.135.11.1359
   Google Scholar
• Rubin SB. Margin of Error: The Ethics of Mistakes in the Practice of Medicine. Hagerstown (MD): University Publishing; 2000:374.
   Google Scholar
• Aasland OG, Forde R. Impact of feeling responsible for adverse events on doctors’ personal and professional lives: the importance of being open to criticism from colleagues. Qual Saf Health Care. 2005;14(1):13–17. doi:10.1136/qshc.2002.003657
   Google Scholar
• Coulehan J. A gentle and humane temper”: humility in medicine. Perspect Biol Med. 2011;54(2):206–216. doi:10.1353/pbm.2011.0017
   PubMed Web of Science ®Google Scholar
• Berger AS. Arrogance among physicians. Acad Med. 2002;77(2):145–147.
   PubMed Web of Science ®Google Scholar
• Tang CJ, Chan SW, Zhou WT, Liaw SY. Collaboration between hospital physicians and nurses: an integrated literature review. Int Nurs Rev. 2013;60(3):291–302. doi:10.1111/inr.12034
   PubMed Web of Science ®Google Scholar
• Holroyd-Leduc JM, Straus SE. MeToo and the medical profession. CMAJ. 2018;190(33):E972–E973. doi:10.1503/cmaj.181037
   Web of Science ®Google Scholar
• Dyrbye LN, Burke SE, Hardeman RR, et al. Association of clinical specialty with symptoms of burnout and career choice regret among US resident physicians. JAMA. 2018;320(11):1114–1130. doi:10.1001/jama.2018.12615
   PubMed Web of Science ®Google Scholar
• Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165(11):753–760. doi:10.7326/M16-0961
   PubMed Web of Science ®Google Scholar
• Jenner S, Djermester P, Prügl J, Kurmeyer C, Oertelt-Prigione S. Prevalence of Sexual Harassment in Academic Medicine. JAMA Intern Med. 2019;179(1):108–111. doi:10.1001/jamainternmed.2018.4859.
   Web of Science ®Google Scholar
• Gupta K, Lisker S, Rivadeneira NA, Mangurian C, Linos E, Sarkar U. Decisions and repercussions of second victim experiences for mothers in medicine (SAVE DR MoM). BMJ Qual Saf. 2019;28(7):564–573. doi:10.1136/bmjqs-2018-008372
   Web of Science ®Google Scholar
• Agarwal AK, Murinson BB. New dimensions in patient-physician interaction: values, autonomy, and medical information in the patient-centered clinical encounter. Rambam Maimonides Med J. 2012;3(3):e0017. doi:10.5041/RMMJ.10085
   Google Scholar
• Coughlan B, Powell D, Higgins MF. The second victim: a review. Eur J Obstet Gynecol Reprod Biol. 2017;213:11–16. doi:10.1016/j.ejogrb.2017.04.002
   PubMed Web of Science ®Google Scholar
• Mirza DM. The Bawa-Garba principle for medical error. BMJ. 2018;363:k4112. doi:10.1136/bmj.k4029
   Web of Science ®Google Scholar
• McKinlay JB, Marceau LD. The end of the golden age of doctoring. Int J Health Serv. 2002;32(2):379–416. doi:10.2190/JL1D-21BG-PK2N-J0KD
   PubMed Web of Science ®Google Scholar
• Rosenbaum L. Beyond moral outrage–weighing the trade-offs of COI regulation. N Engl J Med. 2015;372(21):2064–2068. doi:10.1056/NEJMms1502498
   Web of Science ®Google Scholar
• Dyer C. Paediatrician found guilty of manslaughter after boy’s death from septic shock. BMJ. 2015;351:h5969. doi:10.1136/bmj.h6432
   Web of Science ®Google Scholar
• Ritterman JB. To err is human: can American medicine learn from past mistakes? Perm J. 2017;21:16–181. doi:10.7812/TPP/16-181
   Google Scholar
• Mandrola J, Cifu A, Prasad V, Foy A. The case for being a medical conservative. Am J Med. 2019. doi:10.1016/j.amjmed.2019.02.005
   Web of Science ®Google Scholar
• Ozeke O, Cay S, Ozcan F, Topaloglu S, Aras D. Post-truth era and cardiology: after ORBITA, before CABANA. Indian Heart J. 2018;70(3):439–442. doi:10.1016/j.ihj.2018.04.005
   Google Scholar
• Ozeke O, Aras D, Cay S, et al. Perception paradox between the doctors and patients in the industrial-bureaucratic age of medicine: defensive versus offensive medicine in anticoagulation and atrial fibrillation ablation. Pacing Clin Electrophysiol. 2017;40(8):979–980. doi:10.1111/pace.13124
   Web of Science ®Google Scholar
• Jacobs AK, American Heart A. Rebuilding an enduring trust in medicine: a global mandate: presidential address American Heart Association Scientific Sessions 2004. Circulation. 2005;111(25):3494–3498. doi:10.1161/CIRCULATIONAHA.105.166277
   PubMed Web of Science ®Google Scholar
• Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000. PubMed PMID: 25077248.
   Google Scholar
• Bohnen JD, Lillemoe KD, Mort EA, Kaafarani HMA. When things go wrong: the surgeon as second victim. Ann Surg. 2019;269(5):808–809. doi:10.1097/SLA.0000000000003138
   PubMed Web of Science ®Google Scholar