Mary Higgins: The second victim in modern healthcare

Posted on by BMJ

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First do no harm. It’s one of the fundamental rules, but what experienced clinician has not, at least once, done some harm? Medicine is intricate, and imperfect, with increasing number of diseases and disease processes occurring in complex people within a multifaceted world. The tests we use are not perfect and the decisions we make every day are innumerable—and we can do harm.

So lets face this straight on—and talk about the domino effect of medical error. First, as should be, are the patients and their families. The next are “second victims“1 —those clinicians who 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.”2 This is common—nearly three out of four of us may be affected.3 Finally, the third victim is the organisation where the error occurred.

For centuries clinicians have learnt to deal with the guilt of error. For decades clinicians have sat through morbidity and mortality conferences to discuss these errors. More recently clinicians now have to deal with both the media, and social media, with news coverage of poor outcomes in healthcare, patient blogs where clinicians can be named, online threads, and comments. Behind these stories are real people working within the complexity of healthcare. People who came to work aiming to heal and not harm.  People who may be able to show where the systems have failed and prevent recurrences. People, who if they do not get the support they require, may develop burnout, depression, depersonalisation, emotional exhaustion, all with increased risk for further subsequent errors.

What can be done? Firstly, we can trust second victims (give them treatment, respect, understanding, supportive care, and transparency as opportunity to contribute to enhancing systems of care).4 Secondly, we can consider different patterns of reaction, either constructive (learning from the mistake) or destructive (denial, defense, distancing, discounting). 5-9 Talk to a supportive peer and let us learn to heal—but with the memory of those we have inadvertently harmed and a determination to reduce recurrence.9-10 

To finish with a quote, summarizing all:  ‘‘Healthcare workers who get wrapped up in error and injury, as almost all someday will, get seriously hurt too. And if we’re really 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.’’4

REFERENCES

  1. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-727
  2. Scott, S.D., Hirschinger, L.E., Cox, K.R., McCoig, M., Hahn-Cover, K., Epperly, K.M., Phillips, E.C., Hall, L.W., 2010. Caring for our own: deploying a systemwide second victim rapid response team. The Joint Commission Journal on Quality and Patient Safety 36 (5), 233–240.
  3. Mira JJ, Carrillo I, Lorenzo S, Ferrus L et al. Te aftermath of adverse events in Spanish primary care and hospital health professionals. BMC Health Services Research 2015; 15:151-160
  4. Denham, C.R., 2007. TRUST: the 5 rights of the second victim. Journal of Patient Safety 3 (2), 107–119.
  5. Wu, A. W., Folkman, S., McPhee, S. J., & Lo, B. (1993). How house officers cope with their mistakes. Western Journal of Medicine, 159, 565–569.
  6. Christensen, J. F., Levinson, W., & Dunn, P. M. (1992). The heart of darkness: The impact of perceived mistakes on physicians. Journal of General Internal Medicine, 7, 424–431.
  7. Chard, R. (2010). How perioperative nurses define, attribute causes of, and react to intraoperative nursing errors. AORN Journal, 91, 132–145.
  8. Seys D, Wu A, Van Gerven E, Vleugels A, Euwema M. Planella M, Scott S, Conway J, Sermeus W, Vanhaecht K. (2013)Health Care Professionals as Second Victims after Adverse Events: A Systematic Review. Evaluation & the Health Professions 36(2) 135-162
  9. MeurierC.E, Vincent C.A, & ParmarP.G. (1998). Nurses responses to serverity dependent error: a study of the causal attributions mad by Nurses following an error. Journal of Advanced Nursing 27, 349-354
  10. van Pelt F. Peer support: healthcare professionals supporting each other after adverse medical events Qual Saf Health Care 2008;17:249– PubMed;252

Mary Higgins is an obstetrician at the National Maternity Hospital, University College Dublin.

Competing interests: None declared.