Eva Van Gerven

Health Care Professionals as Second Victims after Adverse Events A Systematic Review

Adverse events within health care settings can lead to two victims. The first victim is the patient and family and the second victim is the involved health care professional. The latter is the focus of this review. The objectives are to determine definitions of this concept, research the prevalence and the impact of the adverse event on the second victim, and the used coping strategies. Therefore a literature research was performed by using a three-step search procedure. A total of 32 research articles and 9 nonresearch articles were identified. The second victim phenomenon was first described by Wu in 2000. In 2009, Scott et al. introduced a detailed definition of second victims. The prevalence of second victims after an adverse event varied from 10.4% up to 43.3%. Common reactions can be emotional, cognitive, and behavioral. The coping strategies used by second victims have an impact on their patients, colleagues, and themselves. After the adverse event, defensive as well as constructive changes have been reported in practice. The second victim phenomenon has a significant impact on clinicians, colleagues, and subsequent patients. Because of this broad impact it is important to offer support for second victims. When an adverse event occurs, it is critical that support networks are in place to protect both the patient and involved health care providers.

Supporting involved health care professionals (second victims) following an adverse health event: A literature review

BACKGROUND One out of seven patients is involved in an adverse event. The first priority after such an event is the patient and their family (first victim). However the involved health care professionals can also become victims in the sense that they are traumatized after the event (second victim). They can experience significant personal and professional distress. Second victims use different coping strategies in the aftermath of an adverse event, which can have a significant impact on clinicians, colleagues, and subsequent the patients. It is estimated that nearly half of health care providers experience the impact as a second victim at least once in their career. Because of this broad impact it is important to offer support. OBJECTIVE The focus of this review is to identify supportive interventional strategies for second victims. STUDY DESIGN An extensive search was conducted in the electronic databases Medline, Embase and Cinahl. We searched from the start data of each database until September 2010. RESULTS A total of 21 research articles and 10 non-research articles were identified in this literature review. There are numerous supportive actions for second victims described in the literature. Strategies included support organized at the individual, organizational, national or international level. A common intervention identified support for the health care provider to be rendered immediately. Strategies on organizational level can be separated into programs specifically aimed at second victims and more comprehensive programs that include support for all individuals involved in the adverse event including the patient, their family, the health care providers, and the organization. CONCLUSION Second victim support is needed to care for health care workers and to improve quality of care. Support can be provided at the individual and organizational level. Programs need to include support provided immediately post adverse event as well as on middle long and long term basis.

Important variations in the content of care pathway documents for total knee arthroplasty may lead to quality and patient safety problems

AIM Reducing variations by standardizing the key interventions in clinical processes is an effective tool to minimize the probability of medical errors. Thus, we determined whether variations exist in the key interventions included in care pathway documents (CPDs) of different organizations and in the timing of these interventions during the care process. METHODS We invited members of the Belgian Dutch Clinical Pathway Network to send their CPDs for external review. We analysed 19 CPDs for total knee arthroplasty. International guidelines were consulted for definition of key interventions. Documentation of these interventions in the pathway documents was checked. RESULTS From the 19 CPDs analysed, we retrieved 18 key interventions. Nine of these key interventions appeared in at least 80% of the care pathways. Only two key interventions appeared in all pathway documents. Nine out of 12 interventions that appeared in at least 80% of the pathway documents showed a variation of 1 day in the timing of care from the median timing. CONCLUSION We conclude that important variation exists in the included interventions and in their timing. The results of this study suggest that, before use in daily patient care, CPDs should be reviewed by peers and checked to ensure that all evidence-based key interventions are included and properly planned. Only in this way can pathways documents be used interprofessionally during the entire perioperative period in the search for optimal quality and patient safety.

Increased Risk of Burnout for Physicians and Nurses Involved in a Patient Safety Incident.

Background:Human errors occur everywhere, including in health care. Not only the patient, but also the involved health professional is affected (ie, the “second victim”). Objectives:To investigate the prevalence of health care professionals being personally involved in a patient safety incident (PSI), as well as the relationship of involvement and degree of harm with problematic medication use, excessive alcohol consumption, risk of burnout, work-home interference (WHI), and turnover intentions. Research Design:Multilevel path analyses were conducted to analyze cross-sectional survey data from 37 Belgian hospitals. Subjects:A total of 5788 nurses (79.4%) and physicians (20.6%) in 26 acute and 11 psychiatric hospitals were included. Measures:“Involvement in a patient safety incident during the prior 6 months,” “degree of harm,” and 5 outcomes were measured using self-report scales. Results:Nine percent of the total sample had been involved in a PSI during the prior 6 months. Involvement in a PSI was related to a greater risk of burnout (&bgr;=0.40, OR=2.07), to problematic medication use (&bgr;=0.33, OR=1.84), to greater WHI (&bgr;=0.24), and to more turnover intentions (&bgr;=0.22). Harm to the patient was a predictor of problematic medication use (&bgr;=0.14, OR=1.56), risk of burnout (&bgr;=0.16, OR=1.62), and WHI (&bgr;=0.19). Conclusions:Second victims experience significant negative outcomes in the aftermath of a PSI. An appropriate organizational response should be provided to mitigate the negative effects.

Variation in 17 obstetric care pathways: potential danger for health professionals and patient safety?

AIM To report a study to determine whether or not variations exist in evidence-based key interventions in pathway documents for normal delivery across hospitals. BACKGROUND Care pathways are used worldwide to standardize and follow up patient-focused care. Minimal variations in pathway documents increase standardization and patient safety. DESIGN A descriptive study design using qualitative methods was used, to examine the various key interventions present in care pathway documents for normal delivery. METHODS Between January-March 2009, we evaluated the content of the care pathway document for normal delivery from 17 different hospitals. The key interventions in these pathways were compared with the 40 evidence-based key interventions of Map of Medicine®. RESULTS There was much variation in the characteristics and the presence of key interventions in the pathway documents. Only 6 of the 40 evidence-based key interventions (15%) were found in all 17 pathway documents and 20 of the 40 interventions (50%) were found in only 10 pathway documents. CONCLUSION If variation already exists among the care pathway documents, this may lead to a high probability of variation in the actual performance of daily care. In this study is shown that, even for highly predictable medical conditions, there are huge differences in the evidence-based content and structure of pathways. Lack of evidence base could potentially endanger both patient safety and the health professional.

The Care Process Self-Evaluation Tool: a valid and reliable instrument for measuring care process organization of health care teams

BackgroundPatient safety can be increased by improving the organization of care. A tool that evaluates the actual organization of care, as perceived by multidisciplinary teams, is the Care Process Self-Evaluation Tool (CPSET). CPSET was developed in 2007 and includes 29 items in five subscales: (a) patient-focused organization, (b) coordination of the care process, (c) collaboration with primary care, (d) communication with patients and family, and (e) follow-up of the care process. The goal of the present study was to further evaluate the psychometric properties of the CPSET at the team and hospital levels and to compile a cutoff score table.MethodsThe psychometric properties of the CPSET were assessed in a multicenter study in Belgium and the Netherlands. In total, 3139 team members from 114 hospitals participated. Psychometric properties were evaluated by using confirmatory factor analysis (CFA), Cronbach’s alpha, interclass correlation coefficients (ICCs), Kruskall-Wallis test, and Mann–Whitney test. For the cutoff score table, percentiles were used. Demographic variables were also evaluated.ResultsCFA showed a good model fit: a normed fit index of 0.93, a comparative fit index of 0.94, an adjusted goodness-of-fit index of 0.87, and a root mean square error of approximation of 0.06. Cronbach’s alpha values were between 0.869 and 0.950. The team-level ICCs varied between 0.127 and 0.232 and were higher than those at the hospital level (0.071-0.151). Male team members scored significantly higher than females on 2 of the 5 subscales and on the overall CPSET. There were also significant differences among age groups. Medical doctors scored significantly higher on 4 of the 5 subscales and on the overall CPSET. Coordinators of care processes scored significantly lower on 2 of the 5 subscales and on the overall CPSET. Cutoff scores for all subscales and the overall CPSET were calculated.ConclusionsThe CPSET is a valid and reliable instrument for health care teams to measure the extent care processes are organized. The cutoff table permits teams to compare how they perceive the organization of their care process relative to other teams.

Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis

Objective To examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on physicians, nurses and midwives. Design Cross-sectional, retrospective surveys of physicians, midwives and nurses. Setting 33 Belgian hospitals. Participants 913 clinicians (186 physicians, 682 nurses, 45 midwives) involved in a patient safety incident. Main outcome measures The Impact of Event Scale was used to retrospectively measure psychological impact of the safety incident at the time of the event and compare it with psychological impact at the time of the survey. Results Individual, situational as well as organisational aspects influenced psychological impact and recovery of a patient safety incident. Psychological impact is higher when the degree of harm for the patient is more severe, when healthcare professionals feel responsible for the incident and among female healthcare professionals. Impact of degree of harm differed across clinicians. Psychological impact is lower among more optimistic professionals. Overall, impact decreased significantly over time. This effect was more pronounced for women and for those who feel responsible for the incident. The longer ago the incident took place, the stronger impact had decreased. Also, higher psychological impact is related with the use of a more active coping and planning coping strategy, and is unrelated to support seeking coping strategies. Rendered support and a support culture reduce psychological impact, whereas a blame culture increases psychological impact. No associations were found with job experience and resilience of the health professional, the presence of a second victim support team or guideline and working in a learning culture. Conclusions Healthcare organisations should anticipate on providing their staff appropriate and timely support structures that are tailored to the healthcare professional involved in the incident and to the specific situation of the incident.

Is variation in the content of care pathways leading to quality and patient safety problems

770 Standardising care processes is an effective way to improve patient safety and quality of care (1). Care pathways are used worldwide to standardise the work of multidisciplinary teams, to optimise team effectiveness and efficiency when treating various patient groups, and to make care processes transparent (2). Pathways are typically developed for high-volume and predictable patient groups, such as patients undergoing total hip arthroplasty (THA). Orthopaedics is one of the medical disciplines in which care pathways are commonly used but debate remains about the overall impact on patient care (3). An explanation is the variation in content of the documents used and the in way care pathwaya are applied in daily clinical practice (3). A recent study showed a large variation in the evidencebased content of care pathway documents (CPD) used for THA. Eighteen CPD for THA from 18 member organizations of the Belgian Dutch Clinical Pathway Network (4) were analysed. The participating hospitals were asked to send the documents they were using for guidance in the daily management of THA patients to Leuven University for content analysis. Ninety-two different clinical activities were found in the 18 CPD. A set of 18 key interventions was defined based on the guidelines from the British Orthopaedic Association, the American Academy of Orthopedic Surgeons, the National Institute for Health and Clinical Excellence and the Map of Medicine® (Tab. I). The prevalence of these key interventions in the CPD was verified by two independent researchers. Only one key intervention (wound drain removal) appeared in all 18 paIs variation in the content of care pathways leading to quality and patient safety problems?