Editor ial
Editorial
ar Layar
Support for “second victims”
A
split second is all it takes to change your life—or someone else’s—forever. I know: My split second came when I dispensed an overdose of potassium to a two-year-old girl. The code team worked on her unsuccessfully for over two hours, knowing their attempts were futile but unwilling to give up. When she died cradled in her mother’s arms that day, she became the first victim; I became the second. “Second victims” are healthcare providers involved in an unanticipated, adverse patient-related event that is traumatizing to the provider. As described in an article (see page 563 in this issue of the Journal) by Krzan et al.,1 second victims are largely left to deal with the aftermath of traumatizing events on their own. Few organizations have formal programs for helping second victims such as that created at Nationwide Children’s Hospital (the Ohio institution whose program was the focus of the article). Looking back, I realize that I am actually one of the fortunate second victims (if there can be such a thing). I received compassionate, timely, and much-needed support after the event, which is not the case for many who have experienced what I did. I was also fortunate in working for an organization that was committed to transparency and honesty and that immediately and fully disclosed to the family what had happened. Instead of hiding what had happened, my organization used it to motivate people to work toward positive change. The hospital leadership shared the story with the entire staff and empowered me to help build safety programs around what we had learned about our weaknesses in delivering safe care. We worked collaboratively with outside organizations such as the Institute for Healthcare Improvement and the Robert Wood Johnson Foundation, and we studied multiple other health systems to improve our processes. We continued to foster open and honest communication—not just with patients and families but with the hospital’s employees. Allowing for open communication helps immensely in promoting the healing of second victims, as it makes healthcare staff feel safe to discuss events with peers and places the focus on improving systems and safety rather than pointing fingers at individuals involved in traumatizing events. At the risk of seeming overly dramatic, I will tell you that the mental anguish that accompanies earning the title “second victim” is far worse than any punishment any boss or other human could impose. Knowing you had a hand in the death of another human being is unbelievably and indescribably
Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0401-0523.
terrible and painful. As with many things in life, the pain subsides with time but never leaves you. My career path changed completely after this event: Patient safety became my primary focus and passion. I’m sure many of my peers saw this as a coping mechanism, and perhaps they were correct, but channeling pain and regret into something positive is what has allowed me to remain in pharmacy. Experience has shown that the most common errors in healthcare are human errors. We know that through good system design we can reduce the risk of these errors, but we need to fight the natural human instinct to blame individuals because, it is clear, that will not “fix” the problem. Since first sharing my story outside of the hospital, I’ve met a lot of healthcare second victims. There are many of us out there, and some are still afraid and ashamed to speak out. But many of us are now among the most driven, passionate advocates for a safer healthcare system. We need to continue to implement well-designed, formalized programs to assist second victims. The template already exists, as illustrated by the experience at Nationwide Children’s Hospital; and, as that hospital’s employee surveys have shown, formalized second victim support is both wanted and needed.1 In these programs, we need to ensure that the appropriate level of support is offered, with the intervention process centered around peers as the primary providers of initial support. Policies that prevent punishment as the predominant response to human error in healthcare need to be implemented. We need to create a culture of learning in which stories are shared and disclosure at all levels becomes the norm. Allowing open and honest communication is key in reducing the personal blame and shame a second victim suffers. Understanding why and how errors occur, and then working to reduce the chances they could happen again, are crucial to healing; this isn’t just about pharmacy, but we can certainly start in our own profession. Human error happens every day. Second victims are created every day. Let’s continue to work to recognize human error for what it is, create strategies to mitigate risk, and support individuals involved in catastrophic, traumatic events. 1. Krzan KD, Merandi J, Morvay S, Mirtallo J. Implementation of a “second victim” program in a pediatric hospital. Am J Health-Syst Pharm. 2015; 72:563-7.
Natasha Nicol, Pharm.D., FASHP, Director of Global Patient Safety Affairs Cardinal Health [email protected] The author has declared no potential conflicts of interest. DOI 10.2146/ajhp150131 Am J Health-Syst Pharm—Vol 72 Apr 1, 2015
523
Editorial
ar Layar
Support for “second victims”
A
split second is all it takes to change your life—or someone else’s—forever. I know: My split second came when I dispensed an overdose of potassium to a two-year-old girl. The code team worked on her unsuccessfully for over two hours, knowing their attempts were futile but unwilling to give up. When she died cradled in her mother’s arms that day, she became the first victim; I became the second. “Second victims” are healthcare providers involved in an unanticipated, adverse patient-related event that is traumatizing to the provider. As described in an article (see page 563 in this issue of the Journal) by Krzan et al.,1 second victims are largely left to deal with the aftermath of traumatizing events on their own. Few organizations have formal programs for helping second victims such as that created at Nationwide Children’s Hospital (the Ohio institution whose program was the focus of the article). Looking back, I realize that I am actually one of the fortunate second victims (if there can be such a thing). I received compassionate, timely, and much-needed support after the event, which is not the case for many who have experienced what I did. I was also fortunate in working for an organization that was committed to transparency and honesty and that immediately and fully disclosed to the family what had happened. Instead of hiding what had happened, my organization used it to motivate people to work toward positive change. The hospital leadership shared the story with the entire staff and empowered me to help build safety programs around what we had learned about our weaknesses in delivering safe care. We worked collaboratively with outside organizations such as the Institute for Healthcare Improvement and the Robert Wood Johnson Foundation, and we studied multiple other health systems to improve our processes. We continued to foster open and honest communication—not just with patients and families but with the hospital’s employees. Allowing for open communication helps immensely in promoting the healing of second victims, as it makes healthcare staff feel safe to discuss events with peers and places the focus on improving systems and safety rather than pointing fingers at individuals involved in traumatizing events. At the risk of seeming overly dramatic, I will tell you that the mental anguish that accompanies earning the title “second victim” is far worse than any punishment any boss or other human could impose. Knowing you had a hand in the death of another human being is unbelievably and indescribably
Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0401-0523.
terrible and painful. As with many things in life, the pain subsides with time but never leaves you. My career path changed completely after this event: Patient safety became my primary focus and passion. I’m sure many of my peers saw this as a coping mechanism, and perhaps they were correct, but channeling pain and regret into something positive is what has allowed me to remain in pharmacy. Experience has shown that the most common errors in healthcare are human errors. We know that through good system design we can reduce the risk of these errors, but we need to fight the natural human instinct to blame individuals because, it is clear, that will not “fix” the problem. Since first sharing my story outside of the hospital, I’ve met a lot of healthcare second victims. There are many of us out there, and some are still afraid and ashamed to speak out. But many of us are now among the most driven, passionate advocates for a safer healthcare system. We need to continue to implement well-designed, formalized programs to assist second victims. The template already exists, as illustrated by the experience at Nationwide Children’s Hospital; and, as that hospital’s employee surveys have shown, formalized second victim support is both wanted and needed.1 In these programs, we need to ensure that the appropriate level of support is offered, with the intervention process centered around peers as the primary providers of initial support. Policies that prevent punishment as the predominant response to human error in healthcare need to be implemented. We need to create a culture of learning in which stories are shared and disclosure at all levels becomes the norm. Allowing open and honest communication is key in reducing the personal blame and shame a second victim suffers. Understanding why and how errors occur, and then working to reduce the chances they could happen again, are crucial to healing; this isn’t just about pharmacy, but we can certainly start in our own profession. Human error happens every day. Second victims are created every day. Let’s continue to work to recognize human error for what it is, create strategies to mitigate risk, and support individuals involved in catastrophic, traumatic events. 1. Krzan KD, Merandi J, Morvay S, Mirtallo J. Implementation of a “second victim” program in a pediatric hospital. Am J Health-Syst Pharm. 2015; 72:563-7.
Natasha Nicol, Pharm.D., FASHP, Director of Global Patient Safety Affairs Cardinal Health [email protected] The author has declared no potential conflicts of interest. DOI 10.2146/ajhp150131 Am J Health-Syst Pharm—Vol 72 Apr 1, 2015
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