Keeping Clients Safe: Error and Safety in Behavioral Health Settings _ ________________________________
• Translation services Researchers expressed concern that The Joint Commission, while encouraging facilities to identify their policies for investigating sentinel events—including voluntary reporting of adverse safety events—did not provide policy or language that addressed either trauma-informed care or the importance of safety culture. Shields and colleagues (2018) argued that this exemplified leadership falling short of the needed regulatory guidance and monitoring, practices that ought to be expected from The Joint Commission. Unfortunately, states do not often create regulatory standards that exceed those of The Joint Commission or the Center for Medicare and Medicaid Services. Researchers argue that states are deficient in their regulatory patient safety mandate and are in need of systematic, evidence-based improvements (Frogner et al., 2020). Because of this, researchers have exam- ined the regulatory role of states, which create licensing rules that inpatient facilities must follow. In a sample of six states, research demonstrated that rules varied considerably from state to state, with a mélange of regulations that appear somewhat ambivalent—in practice—toward standards to ensure patient safety. Regulators cannot be complacent and at the same time call for patient safety. For example, for the six states sampled by Shields and colleagues (2018), there was “limited information describing states’ trend analyses of critical incidents, which suggests that states do not systematically track and publicly report aggregated rates of complaints . . . furthermore, states differ in their transparency with critical incidents and regula- tory violations” (p. 1857).
It was with immeasurable sadness that we learned a veteran pediatric nurse had taken her own life in the aftermath of a fatal medication error. The nurse, Kimberly, age 50, committed suicide on April 3, 2011, just 7 months after making a mathematical error that resulted in an overdose of calcium chloride and the subsequent death of a critically ill infant. According to media reports, after investigation of the event, hospital leaders made a difficult decision to terminate Kimberly’s employment after 27 years of service for undisclosed reasons, including factors not directly associated with the event. To satisfy state licensing disciplinary actions, Kimberly agreed to pay a fine and accepted a four-year probation that included medication administration supervision at any future nursing job. Just before her death, she had aced an advanced cardiac life support certification examination to qualify for a flight nurse position. But according to media reports, this and countless other efforts produced no job offers, increasing her isolation, despair, and depression. As a testament to her long- standing compassionate and competent nursing care, many patients and families who received care from Kimberly attended her memorial service to honor her. Patient safety programming and research appears to be robust globally; however, scholars argue that efforts to manage the aftermath of adverse patient events appear to be trailing behind. Given this, Danish researchers investigated the efficacy of a structured peer support program for clinical profession- als who have been negatively affected as second victims. The “Buddy Study” (Schrøder et al., 2022) involved more than 250 healthcare providers—physicians, midwives, and nursing assistants. The program design centered around a two-hour educational seminar explaining the nature of second victimiza- tion and the usefulness of self-selecting a professional peer as a support person should this phenomenon occur. Follow-up indicated that healthcare staff found the educational seminar to be informative and contributed to staff members reporting greater feelings of safety and professional support. The research- ers concluded that a formalized peer support program of this kind should be widely researched to verify that it could be a complementary program to ensure the overall safety of staff and patients (Schrøder et al., 2022). EMOTIONAL IMPACT OF MEDICAL ERRORS Victims of medical mistakes—patients, families, and profes- sionals—are similar in many ways to victims of other types of traumas as they experience frequent images and/or thoughts of the events that are triggered by nonspecific occurrences. But the sense of betrayal, loss of trust, isolation, and height- ened vulnerability felt by both patients and their families is
IMPACT ON HEALTHCARE PROFESSIONALS
Clinicians involved in errors that harm their patients also suffer psychologically and thus are referred to as the second victims of medical mistakes (Burlison et al., 2017). In addition to guilt, sleep disturbance, and depression, second victims lose self-confidence, question their self-worth, are anxious about committing future errors, and are vulnerable to burnout and job dissatisfaction (Schwappach & Boluarte, 2008). A corre- lation has been found between poor well-being of healthcare professionals and worse patient safety. Additionally, researchers concluded that this phenomenon is so critical that program- ming to support second victims for their own well-being and the safety of patients that they serve (Jung et al., 2022) is needed. The following excerpt from a newsletter of the Institute for Safe Medication Practices (2011) portrays how a medical error had tragic consequence for a second victim.
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