Quality Improvement in Health Care (한국의료질향상학회지)

Korean Society for Quality in Health Care (한국의료질향상학회)
권호 표지
DOI QR코드

DOI QR Code

Trends in Second Victim Support Programs for Healthcare Providers: A Literature Review

환자안전사건을 경험한 의료진을 위한 제2의 피해자 지원 프로그램의 동향

  • Eun Young Choi (Department of Nursing, Chung-Ang University) ;
  • Jeehee Pyo (Task Forces to Support Public Health and Medical Services in Ulsan Metropolitan City) ;
  • Seung Kyoung Jang (College of Nursing, Inje University) ;
  • Won Lee (Department of Nursing, Chung-Ang University) ;
  • Minsu Ock (Task Forces to Support Public Health and Medical Services in Ulsan Metropolitan City) ;
  • Haeyoung Lee (Department of Nursing, Chung-Ang University)
  • 최은영 (중앙대학교 간호학과) ;
  • 표지희 (울산광역시 공공보건의료지원단) ;
  • 장승경 (인제대학교 간호대학) ;
  • 이원 (중앙대학교 간호학과) ;
  • 옥민수 (울산광역시 공공보건의료지원단) ;
  • 이해영 (중앙대학교 간호학과)
  • Received : 2023.04.08
  • Accepted : 2023.06.09
  • Published : 2023.06.30
Download PDF
⟨ Previous Next ⟩

Abstract

Purpose: This study aimed to review second victim support programs to identify effective evidence-based strategies for supporting healthcare providers involved in patient safety incidents. Methods: A comprehensive review search was conducted, including a search of databases, gray literature, and a hand-search of related fields, with "second victim" as the main search term. Results: We reviewed nine second victim support programs, focusing on their development process, operating form, and performance. These were (a) Peer Support Services, (b) forYOU team, (c) YOU Matter, (d) Resilience in Stressful Events, (e) Clinician Peer Support Program, (f) SWADDLE, (g) Surgery Second Victim Peer Support Program, (h) Caring for the Caregiver, and (i) Code Lavender. Conclusion: Second victim support programs help solve the emotional problems of medical staff caused by patient safety incidents. Therefore, it is necessary to develop a second victim support program suitable for the medical environment in Korea.

Keywords

Acknowledgement

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. 2018R1C1B6005186). This work was also supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. 2022R1C1C1006810). The funder had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

References

  1. Hilfiker D. Facing our mistakes. New England journal of medicine. 1984;310(2):118-22.  https://doi.org/10.1056/NEJM198401123100211
  2. Levinson W, Dunn P M. A piece of my mind. Coping with fallibility. The Journal of the American Medical Association. 1989;261(15):2252. 
  3. Wu AW. Medical error: the second victim: The doctor who makes the mistake needs help too. The British Medical Journal. 2000;320(7237):726-7.  https://doi.org/10.1136/bmj.320.7237.726
  4. Seys D, Wu AW, Van Gerven E, Vleugels A, Euwema M, Panella M, et al. Health care professionals as second victims after adverse events: a systematic review. Evaluation & the Health Professions. 2013;36(2):135-62.  https://doi.org/10.1177/0163278712458918
  5. Mira JJ, Carrillo I, Lorenzo S, Ferrus L, Silvestre C, Perez-Perez P et al. The aftermath of adverse events in Spanish primary care and hospital health professionals. BMC Health Services Research. 2015;15(1):151 
  6. 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. Quality & safety in health care. 2009;18(5):325-30.  https://doi.org/10.1136/qshc.2009.032870
  7. Busch IM, Moretti F, Purgato M, Barbui C, Wu AW, Rimondini M. Psychological and psychosomatic symptoms of second victims of adverse events: a systematic review and meta-analysis. Journal of Patient Safety. 2020;16(2):e61-e74.  https://doi.org/10.1097/PTS.0000000000000589
  8. Burlison JD, Quillivan RR, Scott SD, Johnson S, Hoffman JM. The effects of the second victim phenomenon on work-related outcomes: connecting self-reported caregiver distress to turnover intentions and absenteeism. Journal of Patient Safety. 2021;17(3):195-99.  https://doi.org/10.1097/PTS.0000000000000301
  9. Kable A, Kelly B, Adams J. Effects of adverse events in health care on acute care nurses in an Australian context: A qualitative study. Nursing & Health Sciences. 2018;20(2):238-46.  https://doi.org/10.1111/nhs.12409
  10. Quillivan RR, Burlison JD, Browne EK, Scott SD, Hoffman JM. Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses. The Joint Commission Journal on Quality and Patient Safety. 2016;42(8):377-86.  https://doi.org/10.1016/S1553-7250(16)42053-2
  11. West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. The Journal of the American Medical Association. 2006;296(9):1071-8.  https://doi.org/10.1001/jama.296.9.1071
  12. Ozeke O, Aras S, Baser K, Sen F, Kirbas O, Cay S, et al. Defensive medicine due to different fears by patients and physicians in geriatric atrial fibrillation patients and second victim syndrome. International Journal of Cardiology. 2016;212:251-2.  https://doi.org/10.1016/j.ijcard.2016.03.093
  13. National Quality Forum. Safe practices for better healthcare-2010 Update [Internet]. Washington DC, United States of America: National Quality Forum; 2010 [cited 2023 Apr 03]. Available from: https://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx. 
  14. The Joint Commission. Quick safety: supporting second victims [Internet]. Illinois, United States of America: The Joint Commission; 2018 [cited 2023 Apr 13]. Available from: www.jointcommission.org/assets/1/23/Quick_Safety_Issue_39_2017_Second_victim_FINAL2.pdf. 
  15. Wade L, Fitzpatrick E, Williams N, Parker R, Hurley KF. Organizational Interventions to Support Second Victims in Acute Care Settings: A Scoping Study. Journal of Patient Safety. 2022;18(1):e61-e72.  https://doi.org/10.1097/PTS.0000000000000704
  16. Choi EY, Pyo J, Ock M, Lee H. Profiles of second victim symptoms and desired support strategies among Korean nurses: A latent profile analysis. Journal of Advanced Nursing. 2022;78(9):2872-83.  https://doi.org/10.1111/jan.15221
  17. Choi EY, Pyo J, Lee W, Jang SG, Park YK, Ock M, et al. Nurses' experiences of patient safety incidents in Korea: a cross-sectional study. BMJ Open. 2020;10(10):e037741. 
  18. Pyo J, Choi EY, Lee W, Jang SG, Park YK, Ock M, et al. Physicians' difficulties due to patient safety incidents in Korea: a cross-sectional study. Journal of Korean medical science. 2020;35(17):e118. 
  19. Lee W, Pyo J, Jang SG, Choi JE, Ock M. Experiences and responses of second victims of patient safety incidents in Korea: a qualitative study. BMC Health Services Research. 2019;19(1):100. 
  20. Lee SS, Huh JH, Koo MS, Kim SH, Woo MH, Nam SM et al. (2019). Investigation of working conditions of hospital nurses [Internet]. Seoul: Korea: Hospital Nurses Association; 2019 [cited 2023 Apr 13]. Available from: https://khna.or.kr/home/pds/utilities.php. 
  21. Van Pelt F. Peer support: healthcare professionals supporting each other after adverse medical events. Quality & safety in health care. 2008;17(4):249-52.  https://doi.org/10.1136/qshc.2007.025536
  22. Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Academic Medicine. 2016;91(9):1200-4.  https://doi.org/10.1097/ACM.0000000000001297
  23. Scott SD, Hirschinger LE, Cox KR, McCoig M, Hahn-Cover K, Epperly KM, et al. Caring for our own: deploying a systemwide second victim rapid response team. Joint Commission Journal on Quality and Patient Safety. 2010;36(5):233-40.  https://doi.org/10.1016/S1553-7250(10)36038-7
  24. Hirschinger LE, Scott SD, Hahn-Cover K. Clinician support: five years of lessons learned [Internet]. Massachusetts, USA; Patient Safety and Quality Healthcare; 2015. [cited 2023 Apr 13]. Available from: https://www.psqh.com/analysis/clinician-support-five-years-of-lessons-learned/. 
  25. Scott SD. Second victim support: Implications for patient safety attitudes and perceptions [Internet]. MA, United States of America: Patient Safety and Quality Healthcare; 2015 [cited 2023 Apr 13]. Available from: https://www.psqh.com/analysis/second-victim-support-implications-for-patient-safety-attitudes-and-perceptions/. 
  26. Krzan KD, Merandi J, Morvay S, Mirtallo J. Implementation of a "second victim" program in a pediatric hospital. American journal of health-system pharmacy. 2015;72(7):563-7.  https://doi.org/10.2146/ajhp140650
  27. Merandi J, Liao N, Lewe D, Morvay S, Stewart B, Catt C, et al. Deployment of a second victim peer support program: A Replication Study. Pediatric quality & safety. 2017;2(4):e031. 
  28. Merandi J, Winning AM, Liao N, Rogers E, Lewe D, Gerhardt CA. Implementation of a second victim program in the neonatal intensive care unit: an interim analysis of employee satisfaction. Journal of Patient Safety and Risk Management. 2018;23(6):231-8.  https://doi.org/10.1177/2516043518809457
  29. 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. 
  30. Dukhanin V, Edrees HH, Connors CA, Kang E, Norvell M, Wu AW. Case: a second victim support program in pediatrics: successes and challenges to implementation. Journal of Pediatric Nursing. 2018;41:54-9.  https://doi.org/10.1016/j.pedn.2018.01.011
  31. Moran D, Wu AW, Connors C, Chappidi MR, Sreedhara SK, Selter JH, et al. Cost-benefit analysis of a support program for nursing staff. Journal of Patient Safety. 2020;16(4):e250-4.  https://doi.org/10.1097/PTS.0000000000000376
  32. Lane MA, Newman BM, Taylor MZ, O'Neill M, Ghetti C, Woltman RM, et al. Supporting clinicians After adverse events: development of a clinician peer support program. Journal of Patient Safety. 2018;14(3):e56-60.  https://doi.org/10.1097/PTS.0000000000000508
  33. Trent M, Waldo K, Wehbe-Janek H, Williams D, Hegefeld W, Havens L. Impact of health care adversity on providers: Lessons learned from a staff support program. Journal of Healthcare Risk Management. 2016;36(2):27-34.  https://doi.org/10.1002/jhrm.21239
  34. Bohnen JD, Lillemoe KD, Mort EA, Kaafarani HMA. When things go wrong: the surgeon as second victim. Annals of Surgery. 2019;269(5):808-9.  https://doi.org/10.1097/SLA.0000000000003138
  35. University of California San Francisco Healthcare. caring for the caregiver brochure [Internet]. California, United States of America: University of California San Francisco Healthcare; 2018 [cited 2023 Apr 13]. Available from: https://caringforthecaregiver.ucsf.edu/sites/g/files/tkssra1801/f/wysiwyg/Caring%20for%20the%20Caregiver%20Brochure%202018.pdf. 
  36. Johnson B. Code Lavender: Initiating holistic rapid response at the cleveland clinic. Beginnings. 2014;34(2):10-1. 
  37. Stone RSB. Code Lavender: A tool for staff support. Nursing. 2018;48(4):15-7.  https://doi.org/10.1097/01.NURSE.0000531022.93707.08
  38. Davidson JE, Graham P, Montross-Thomas L, Norcross W, Zerbi G. Code Lavender: Cultivating intentional acts of kindness in response to stressful work situations. Explore. 2017;13(3):181-5. https://doi.org/10.1016/j.explore.2017.02.005