SECOND VICTIM Internationaal & nationaal prof. dr. Kris Vanhaecht dr. Luk Bruyneel Leuvens Instituut voor GezondheidszorgBeleid (LIGB-KULeuven) Dienst kwaliteit, UZ Leuven

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Makary et al, BMJ, 2016

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Prof. Albert Wu Johns Hopkins

BMJ, 2000

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First Victim

Second

Victim

Third

Victim

Impact based on level of

harm ???

Impact based on (Social) Media ?

Impact based on ?? ??

Medical Error Adverse Events Patient Safety Incident (PSI)

“Second victimness”

A B C D E F G H I Categories of harm

S

E

C

O

N

D

V

I

C

T

I

M

N

E

S

S

Twin

Tragedy

Airembolism

Aërosol

?

Woundcare

SodiumCl /

PotassiumCl

Ultrasound

Canule

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No perception of PSI

Adverse reaction

Perc

eive

d r

esp

on

sib

ility

by

oth

ers

Perceived responsibility by self

No

Ye

s

No Yes

DANGER ZONE!!

SV

SV

SV

What is a second victim?

Second Victim definition: A “second victim” is a healthcare professional perceived responsible by oneself or others for an unanticipated patient safety incident. Although the stress-response and coping strategy in the aftermath of this event can vary, the healthcare professional is to some extent affected by this event.

Source: Van Gerven, E., Sermeus, W., Euwema, M., Vanhaecht, K. (2016). PhD dissertation KULeuven.

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Relation error involvement & QoC/PS

Error involvement

Quality of Care Patient Safety

Guilt

Responses to distress: Burnout, depression, diminishing empathy

Frustration

Fear

Source: Swappach & Boluarte, 2009

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What do we already know? Is there some evidence?

50% of all healthcare workers

experience some degree of

second victimness during their career

Prevalence data from Belgian study

Source: Van Gerven, Vander Elst, Vandenbroeck, Dierickx, Euwema, Sermeus, De Witte, Godderis, Vanhaecht, Medical Care, 2016

Study among 5788 Belgian physicians and nurses

1 in 10 involved in PSI within the last 6 months

Dutch study on impact of PSI in 10 hospitals (Leernetwerk Peer Support VvAA)

“Vanhaecht, K., Coeckelberghs, E., Seys, D., Schouten, L., Zeeman, G. (2016). Resultaten Enquête Leernetwerk Peer Support in de zorg: Impact op zorgverleners na betrokkenheid bij een patiëntveiligheidsincident. Onderzoek Leuvens Instituut voor Gezondheidszorgbeleid (LIGB), KULeuven , in opdracht van Leernetwerk Peer Support in de Zorg.”

Vragenlijst bestaat uit 4 delen

Deel 1: DEMOGRAFIE 2387 medewerkers

Feedback op groepsniveau* en per ziekenhuis

Deel 2: PREVALENTIE Betrokkenheid van 2387

medewerkers bij een PVI tijdens hun volledige carrière en voorbije 6

maanden Feedback op groepsniveau en per

ziekenhuis

Deel 3: SYMPTOMEN 1657 medewerkers beschrijven

symptomen na meest memorabele PVI

Feedback op groepsniveau

Deel 4: ONDERSTEUNING 1572 medewerkers beschrijven ondersteuningsmechanismen

Feedback op groepsniveau en per ziekenhuis

* Groepsniveau = de 10 deelnemende ziekenhuizen

“Vanhaecht, K., Coeckelberghs, E., Seys, D., Schouten, L., Zeeman, G. (2016). Resultaten Enquête Leernetwerk Peer Support in de zorg: Impact op zorgverleners na betrokkenheid bij een patiëntveiligheidsincident. Onderzoek Leuvens Instituut voor Gezondheidszorgbeleid (LIGB), KULeuven , in opdracht van Leernetwerk Peer Support in de Zorg.”

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Verdeling soorten PVI zoals beschreven in de casussen (n=1528)

Type Incident Aantal (n=1528)

Medicatiefout 444

Diagnostisch 244

Procedures (allerlei) 243

Valaccident 120

Chirurgisch 101

Onduidelijk 79

Omission 78

Bevalling 75

wrong pat - side – site 73

Agressie 26

Materiaal 24

Suicide 21

“Vanhaecht, K., Coeckelberghs, E., Seys, D., Schouten, L., Zeeman, G. (2016). Resultaten Enquête Leernetwerk Peer Support in de zorg: Impact op zorgverleners na betrokkenheid bij een patiëntveiligheidsincident. Onderzoek Leuvens Instituut voor Gezondheidszorgbeleid (LIGB), KULeuven , in opdracht van Leernetwerk Peer Support in de Zorg.”

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Full Career Within last 6 months

Never been involved in a PSI 368 (15.4%) 1294 (54.2%)

No Harm 566 (23.7%) 586 (24.5%)

Temporary Harm 597 (25.0%) 307 (12.9%)

Permanent Harm 289 (12.1%) 90 (3.8%)

Death 567 (23.8%) 110 (4.6%)

Dutch Study on most severe PSI (n=2387) Full career & within last 6 months

“Vanhaecht, K., Coeckelberghs, E., Seys, D., Schouten, L., Zeeman, G. (2016). Resultaten Enquête Leernetwerk Peer Support in de zorg: Impact op zorgverleners na betrokkenheid bij een patiëntveiligheidsincident. Onderzoek Leuvens Instituut voor Gezondheidszorgbeleid (LIGB), KULeuven , in opdracht van Leernetwerk Peer Support in de Zorg.”

PERSONAL IMPACT PROFESSIONAL IMPACT

Act differently within the team

Insecure feeling in presence of the team members

Act differently in presence of patients and their family

Uncertainty which elevates the chance in making other

mistakes Burnout

>10% thinks about leaving/changing their job

…

Post traumatic stress General stress symptoms

Anger Insomnia

Nervousness Depression

Effect on family life Suicide

…

Women have higher impact than men

Source: Seys et al, 2012, Seys et al 2013, Van Gerven et al, 2016

Symptoms of Second Victimness

Prevalence of symptoms after PSI (n=1641) Dutch Study 2016

“Vanhaecht, K., Coeckelberghs, E., Seys, D., Schouten, L., Zeeman, G. (2016). Resultaten Enquête Leernetwerk Peer Support in de zorg: Impact op zorgverleners na betrokkenheid bij een patiëntveiligheidsincident. Onderzoek Leuvens Instituut voor Gezondheidszorgbeleid (LIGB), KULeuven , in opdracht van Leernetwerk Peer Support in de Zorg.”

Hyper vigilant Shame

Doubting knowledge & skills Stress

Fear Flashbacks

Feeling of not able to provide quality Unhappy & depressed

Uncomfortable within team Insomnia

Fear for claim Attention disorder

Feeling of being lonely Avoiding risks

Burnout Intention to leave discipline or ward

Intention to leave job Wanting to work in other organization

Fear of loosing job

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Impact of PSI on Burnout

• BURNOUT study 5788 Belgian Medical Doctors & Nurses out of 37 hospitals 9,1% had been involved in patient safety incident in previous 6 months

Twofold risk of burnout for physicians and nurses

involved in a patient safety incident

Source: Van Gerven, Vander Elst, Vandenbroeck, Dierickx, Euwema, Sermeus, De Witte, Godderis, Vanhaecht, Medical Care, 2016

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Impact of Adverse Event

on other outcomes

Source: Van Gerven, Vander Elst, Vandenbroeck, Dierickx, Euwema, Sermeus, De Witte, Godderis, Vanhaecht, Medical Care, 2016

Significant higher medication use Significant twofold risk of burnout

Significant WHI Significant Turnover Intentions

BUT ALSO POSITIVE EFFECT AFTER BEING TRAUMATIZED

“From that moment onwards I always agreed to fill in the surgical safety checklist” Chief of Surgery, 2013

“I now always calculate the dose twice” Oncology nurse, 2014

“I am now much more careful while doing the exercises with my hip arthroplasty patients” Junior physiotherapist, 2015

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• Goal: to examine individual, situational and organisational aspects that influence psychological impact and recovery

• Design: Cross sectional retrospective analysis of physicians, nurses and midwives

• Setting & participants: 913 clinicians

out of 33 hospitals who were all involved

in a patient safety incident

• Main outcome: Impact of Event Scale

(measure of psychological impact at

time of incident and at time of

the survey)

Psychological impact & Recovery

Source: Van Gerven, E., Bruyneel, L., Panella, M., Euwema, M., Sermeus, W., Vanhaecht, K. BMJ Open, 2016

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Psychological impact & Recovery

Harm to patient ↑ IES ↑ • patient died: nurse>phys • Severe harm > patient died

Time of incident ↑ IES ↓

Sense of responsability ↑ IES ↑

Female IES ↑

Optimism ↑ IES ↓

Active coping ↑ IES ↑

Self efficacy ↑ IES over time ↓

Source: Van Gerven, E., Bruyneel, L., Panella, M., Euwema, M., Sermeus, W., Vanhaecht, K. BMJ Open, 2016

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Psychological impact & Recovery

Source: Van Gerven, E., Bruyneel, L., Panella, M., Euwema, M., Sermeus, W., Vanhaecht, K. BMJ Open, 2016

Culture of support ↑ IES ↓

Blame culture ↑ IES ↑

Information what happened ↑ IES ↓ Information what to do ↑ IES ↓ Extra guidance ↑ IES ↓

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First Victim

Second

Victim

Third

Victim

Impact based on level of

harm ???

Impact based on (Social) Media ?

Impact based on ?? ??

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• Reactions of managers after PIS are emotional and professional • “As this could happen in my organization, I failed” • “It makes me nervous” • “It gave me lots of additional stress” • “I feel guilty” • “I was angry, because how could this happen in MY hospital?”

IMPACT depends on lots of factors like:

Level of harm to the first victim

Was there contact with victim or family

How many healthcare workers were involved

What is the impact on the second victim

It depends on the personality of the CEO-CMO

Was there contact with the press / media

• Support for third victim: (nearly) NONE

Source: LIGB KULeuven, 2012,unpublished

Interviews with CEO - CMO

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Impact on policy level

Study in 1313 Italian Physicians to understand why they practice

Defensive Medicine

Most prominent predictor for DM = Being a second victim

Source: Panella, M., Rinaldi, C., Leigheb, F., Donnarumma, C., Kul, S., Vanhaecht, K., Di Stanislao, F., 2016

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Support Systems

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No real evidence about support ...

Expressive Writing

Route Cause Analysis

Yoga Mindfulness

Eye Movement Desensitization & Reprocessing

Time-out with a friend

Seys, D., Scott, S., Wu, A., Van Gerven, E., Vleugels, A., Euwema, M., Panella, M., Conway, J., Sermeus, W., Vanhaecht, K. (2013). Supporting involved health care professionals (second victims) following an adverse health event: a literature review. International Journal of Nursing Studies, 50 (5), 678-687.

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“Vanhaecht, K., Coeckelberghs, E., Seys, D., Schouten, L., Zeeman, G. (2016). Resultaten Enquête Leernetwerk Peer Support in de zorg: Impact op zorgverleners na betrokkenheid bij een patiëntveiligheidsincident. Onderzoek Leuvens Instituut voor Gezondheidszorgbeleid (LIGB), KULeuven , in opdracht van Leernetwerk Peer Support in de Zorg.”

Need for support (Dutch study, n=1564)

PSI without harm Temporary harm Permanent harm Fatal harm

Info on content

Info on what’s next

Acknowledging the error

Understanding innocence

Need additional support

Time-out

Who to talk to? (1518 Dutch colleagues)

“Vanhaecht, K., Coeckelberghs, E., Seys, D., Schouten, L., Zeeman, G. (2016). Resultaten Enquête Leernetwerk Peer Support in de zorg: Impact op zorgverleners na betrokkenheid bij een patiëntveiligheidsincident. Onderzoek Leuvens Instituut voor Gezondheidszorgbeleid (LIGB), KULeuven , in opdracht van Leernetwerk Peer Support in de Zorg.”

Own colleagues on ward Other involved teammembers

Partner Colleagues who have PSI experience

Direct managers Involved patient or family

Friends outside of professional work Other managers

Neutral person Psychologist or professionally trained peer

Member of the HRM department General practitioner Insurance physician

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Level 3 - Professional support

Emotional support from psychiatrist/psychologist

Cognitive support to go back to work

Level 2 - Formal support

Emotional support from peer support team

Cognitive support: extra guidance at the work place

Level 1 – Informal/formal support

Emotional/practical support from colleagues and home front

Cognitive support: RCA, information on next steps, open disclosure

Van Gerven, E., Sermeus, W., Euwema, M., Vanhaecht, K. (2016). PhD dissertation KULeuven.

Bring Peer Support in daily practice: organisational

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• Drieluik first second third circulair

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Twitter: #secondvictim / @krisvanhaecht E-mail: kris.vanhaecht@kuleuven.be Web: www.secondvictim.be Or read one of our papers below