The boy stopped breathing. That morning, he had been admitted with what seemed like a seizure to the emergency room at IWK Health Centre in Halifax. He had been given drugs to stop the seizure.
Katrina Hurley, an emergency doctor just starting her night shift and taking over the case, thought the boy was over-sedated from the drugs, and she told this to his parents. As her team resuscitated the child, the parents yelled “You did this!” at Hurley.
The child who suffered multiple, severe health problems had a shunt that was draining fluid from his brain to his abdomen. In reality, that shunt had become blocked. It wasn’t the drugs, but the excess fluid in the brain that was causing his symptoms. He died two days later.
The investigation into his death concluded that even if the shunt failure had been recognized earlier by medical staff, the boy would likely have died anyway. “It wasn’t that we could have saved him but we could have managed it differently,” says Hurley. The boy’s parent’s would have at least known that everything possible was done to save their son.
When Dr. Hurley crawled into bed after that night shift, her mind raced with thoughts of everything she could have done differently. “I was exhausted, because it had been an exhausting night, but sleep couldn’t come to me,” she says. “Every time you close your eyes, you picture the situation.”
Albert Wu, a doctor who has been studying medical errors for more than 15 years, coined the term “second victim” in 2000 to describe health workers who suffer psychologically after an adverse event. In some cases, the health worker may have made an error that contributed to harming a patient; in other cases, a poor outcome or death was simply unexpected and therefore traumatizing.
Currently, most hospitals don’t appear to be doing enough to support second victims. That’s a problem for many reasons, chief among them that “health care is supposed to be designed to take care of people who are suffering and these people are suffering,” says Stephen Pratt, an anesthesiologist and chief of the division of quality and safety in anesthesia at the Beth Israel Deaconess Medical Center in Boston. From a health care system perspective, supporting second victims may reduce health worker turnover and lead to better patient care.
What is a second victim?
The term second victim is problematic, says Pratt. Health workers don’t want to call themselves victims when patients and their families have been harmed. And in the case of medical error, “you don’t feel like a victim. You feel like a perpetrator,” he says. Due to the lack of another accepted term, however, we will use the term.
Research into the phenomenon is still in its infancy, but the few studies available suggest anywhere from 10% to 40% of health workers will experience trauma following an adverse event.
Second victims can experience guilt, anxiety, depression, self-doubt, reduced job satisfaction and frustration. They may find themselves reliving the event days, weeks or months later. The Canadian Medical Protective Association writes that in the case of possible errors, “physicians often harbour visions of disastrous personal consequences, such as the loss of reputation…or revocation of their medical licence.” In severe cases, the person can be diagnosed with post-traumatic stress disorder.
A significant number of second victims rely on their own support network and coping mechanisms to recover after an adverse event, says Hanan Edrees, a patient safety coach at Johns Hopkins University. In some extremes, however, health workers may leave their job, turn to alcohol or other substances, or even commit suicide. In a survey of almost 8,000 American surgeons, those who believed they had made a serious medical error in the previous three months were three times as likely to report they’d contemplated suicide in the previous year. In 2011, Kimberly Hiatt, an ICU nurse in Seattle, committed suicide after she was fired for accidentally giving an infant a ten-fold overdose of calcium, which likely caused the infant’s death.
Anecdotal evidence suggests unsupported health workers may also change their place of work or leave their career altogether due to the psychological stress of a medical incident. Bruce MacLeod, an emergency physician and medical advisor for quality and patient safety at Alberta Health Services, investigated an incident involving a child’s death 20 years ago. No one person “really did anything wrong” and system changes were made as a result. However, three years later, 80% of the “well-trained, caring, experienced nurses” in the large emergency department had moved on, either to another hospital or another career altogether. “In the exit interviews, many people mentioned the stress of this particular case,” says McLeod, who says before the event, staffing had been very stable.
When health workers are supported through adverse events, however, they can provide valuable input in how to prevent errors in the future, says MacLeod.
Most health systems don’t adequately support second victims
Only a handful of formal and comprehensive second victim support programs exist in North America, most of which are US-based.
Shabnum Durrani, director of public affairs for the Ontario Hospital Association, was only aware of two Ontario hospitals that have specific supports in place for second victims (on top of the Employee Assistance Programs that offer counseling to staff for any mental health issue).
Toronto East General Hospital launched a second victim support program in its emergency department in late 2012. After an “unexpected traumatic clinical event,” a health worker or his or her manager can reach out to the ED Care and Support team, which include nurses, a social worker, a patient relations representative and chaplain. A member of this team will provide one-on-one counseling immediately after the event and “at regular intervals afterward,” writes Sharon Navarro, senior consultant in communications at the hospital.
Mount Sinai Hospital in Toronto is providing a three-hour education session to all staff this year on coping with the acute “vicarious trauma” and the “compassion fatigue,” or numbness that can result over time from such encounters, explains Melissa Barton, director of occupational health, wellness and safety at Mount Sinai Hospital. Following major incidents such as a death that is particularly difficult for a team, psychiatrists from the hospital are dispatched to provide group counseling.
Alberta Health Services is taking steps toward developing a province-wide second victim strategy. Over the last year, the organization that oversees health care for the province has established a team of experts to “review the literature and find out what is the best science, what is being done in other organizations, and put together our vision of what the perfect scenario would be,” explains MacLeod.
Without such training and support programs, the culture of medicine can amplify the psychological trauma of a health worker. Both doctors and nurses tend to expect perfection and assign individual responsibility for errors, rather than focus on system responsibility, explains Pratt. That’s partly because if they believe they are individually in control, they believe they can prevent bad things from happening to their patients, he says. In reality, adverse events are “almost never caused by a bad doctor or a bad nurse,” says Wu. “It’s the way that systems are designed so that if you make a slip or you are human in some way, all the other holes were lined up too and the bullet gets through.”
A culture that wants to assign blame is ripe for gossip. In Hurley’s case, the news of the misdiagnosis spread rapidly. “All the nurses were talking about it, and so many stories got told, some of it by people who weren’t actually there,” she says. Days after the boy’s death, Hurley was reviewing another case with a learner, when a nurse asked, “What went wrong with that case?” Hurley was overcome with sadness, at a time when she needed to focus on another patient, and maintain her composure in front of her trainee. “I didn’t want to have an emotional breakdown in front of everybody,” she says.
No one at the hospital reached out to Hurley to see how she was coping but she says hospital managers are currently “discussing” how to better support health workers experiencing similar self-doubt and distress.
Best practices for supporting health workers after an adverse event
No studies have been conducted to robustly evaluate interventions for health workers psychologically affected by medical events so “there is no consensus” on the ideal way to support health workers, says Edrees.
The first peer support program for health workers affected by adverse patient events was launched in 2007 at the University of Missouri Health Care (UMHC). As the director of the Center for Health Services and Outcomes Research at the John’s Hopkins Bloomberg School of Public Health, Wu helped implement a similar program at John’s Hopkins Hospital in 2012.
At these second victim programs, as well as at the second victim program for emergency department staff at Toronto East General Hospital, counsellors aim to immediately administer what’s known as “psychological first aid.” It’s an approach routinely used for disaster responders, firefighters, and children and adults following traumatic events. “Listening is about 90% of it,” says Wu. The approach also involves calming and reassuring the individual, and discussing what coping mechanisms have worked in the past for that person.
The approach replaces “critical incident stress debriefing,” which required people to rehash the event in great detail and wasn’t found to be beneficial and could be harmful in some cases. “It’s not as healthy as we thought it was to regurgitate all the gory details,” says Barton.
Pratt argues, however, that simply having the right kind of counselling available isn’t enough. Educational campaigns need to make health workers aware of the second victim phenomenon, how it affects people and how to identify it. Hospital managers also need to work to combat the stigma around seeking psychological help. This stigma is especially acute for health workers, who are supposed to be the strong caregivers to their patients. “If even taking that business card for counselling in front of your colleagues can feel too shameful, the program won’t work,” explains Pratt.
The Canadian Patient Safety Institute (CPSI) is in the process of integrating information about second victims into its training for quality and safety personnel in hospitals across the country, says Chris Power, CEO of the organization. The organization recently hosted a national conversation on supporting second victims.
Much work remains, however. Formal second victim programs, involving a needs assessment, leadership buy-in, system-wide education and awareness campaigns, can take four years to develop, according to Susan Donnell Scott, who developed UMHC’s program. Medically Induced Trauma Support Services has created several toolkits to guide health care organizations through the process.
In the mean time, health care organizations can raise awareness of second victims in communications to staff and remind staff of psychological help already available to them, suggests Pratt.
Whatever systems are put in place, Power underlines the importance of following up with health workers after an adverse event. Initially, some health workers prefer to “normalize” the situation by focusing on work, she says, and people might only recognize they need help days or weeks later. “These things don’t go away. When you’ve made an error, you think about it for a long time.”