No one wants to minimize the impact of medical errors on patients. But it’s important to understand the resulting impact on involved providers and their organizations. Ignoring these other “victims” of patient safety events can significantly and negatively affect healthcare organizations and overall patient safety.
As such, preventable medical errors really have three victims:
- First Victims: Patients, their families and social networks
- Second Victims: Healthcare practitioners
- Third Victims: Healthcare organizations
And considering the high volume of medical errors that occur annually, the number of “victims” is growing exponentially. In fact, preventable medical errors are a leading cause of death in the United States. Estimates of annual unnecessary deaths range from 98,000, according to the well-known Institution of Medicine “To Err is Human” 1999 report, to more than 440,000, according to a 2015 Journal of Patient Safety Study.
With an average of four clinical providers per inpatient, that means that between 500,000 and 2 million providers could also be impacted each year (and that doesn’t take into account the even higher numbers of medical errors that harm, but don’t kill, their patient victims..
Rightfully so, patients are considered the primary victims of such scenarios. However, healthcare practitioners involved with a preventable medical error oftentimes become second victims — traumatized by the event, plagued with resulting self-doubt, and fearful for their jobs, even when they’ve had longstanding success and previously unblemished records.
In turn, healthcare organizations can then become third victims when they lose one of these valued practitioners, or if a practitioner is no longer as effective as before because of the adverse event’s impact on his or her psyche and work. This of course further breeds a culture of medical errors, and therefore, more first and second victims.
In attempt to break the cycle, healthcare organizations are deploying more support to the second victims of medical errors — the healthcare providers– in addition to focusing on patients.
For instance, the University of Missouri Health System has implemented a framework of support strategies and interventions for its healthcare workers involved in medical error events. The framework focuses on:
- Open discussions of event response plans
- Active identification of second victims
- Immediate interventional support
- “Safe Zones” for sharing concerns/feelings
- Pre-education of event review process and reference guide
The University of Missouri Health System was spurred into action after interviewing and surveying its healthcare practitioners that had been party to various medical error events, and discovering they were experiencing tremendous psychological and social stress.
And while the health system of course wanted to better support and help its invaluable employees, the launch of and continued investment in its second victim support program is not just a feel good exercise: It’s improving practitioner performance, patient event and near miss reporting, root cause analysis, and in effect, patient safety in general.
If you or your organization is interested in better supporting all the victims of patient safety events, learn more about risk management in healthcare.