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 correlation has been found between poor well-being of healthcare professionals and worse patient safety. Additionally, researchers concluded that this phenomenon is so critical that programming 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. 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 Emotional Impact of Medical Errors Victims of medical mistakes—patients, families, and professionals—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 heightened vulnerability felt by both patients and their families is exacerbated in most cases because continued care is needed within the same system that harmed them. Patients and families perceive indifference from caregivers and feel isolated because emotional support is not typically provided when treatment ends (Delbanco & Sigall, 2007). Emotional support and trauma-focused cognitive-behavioral therapy have been suggested as strategies to ameliorate the negative effects of surviving medical error. All victims—be they patients, families, or professionals—express the desire to connect with others who have experienced similar trauma (Delbanco & Sigall, 2007). Involving patients and families in the processing of an adverse event in a structured manner may provide better communication with those affected by the event (Etchegaray et al., 2014). As
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 professionals 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 victimization 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 researchers 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). nursing staff represent that the majority of healthcare staffing, researchers have examined the safety culture within specific units, such as psychiatric inpatient units, to understand if unit safety culture is most salient for promoting patient safety. The research of Cho and Choi (2018) in this domain appears to verify that specific unit safety culture is among the most important factors, especially in the area of communication openness. Feedback and communication about errors, especially with family members, was associated with specific unit safety culture learning and practice. Because little research has been done to measure or identify patient safety competency among acute unit nursing staff, Cho and Choi (2018) sought to define measure and evaluate these factors, identifying attitudes, skills, and knowledge as the core of this type of competency. The authors concluded that nursing safety competency is plastic and can be improved with the right inputs. Case processing and debriefing related to adverse events were identified as useful measures to increase the safety competency of nursing staff.
CONCLUSION
The 1999 IOM report broke through the secrecy surrounding medical errors and fostered the growth of the patient safety movement, creating the research and clinical landscape that exist today. Patient safety has been the focus of many well-intentioned initiatives for more than a decade, but healthcare safety is still a work in progress and needs continual improvement. Few in the scientific and clinical community would dispute this claim. While many admirable projects have been studied and implemented, the overall field of patient safety suffers, as do many clinical fields, from fragmented definitions, insufficient regulatory oversight, and the clinical inertia that allow current practice to simply keep operating. The culture of medicine pervades most behavioral health settings. This cultural attitude can blame clinicians for adverse events rather than focusing on systems. To be safe, healthcare must learn from HROs, which perform high-risk activities with few accidents and adopt the human factors approach that acknowledges human fallibility, focusing on designing work
processes that prevent harm and improve patient safety. Strategies to improve patient safety include safety briefings, root cause analysis, and full disclosure to patients and families about the circumstances surrounding adverse events. Preventable mistakes are just beginning to get the attention they deserve in behavioral health settings. Adverse events that are common in behavioral health settings include suicide, unreported abuse and neglect, and medical illnesses that are misdiagnosed as psychiatric conditions. The Joint Commission has placed these as top priorities for client safety in behavioral health. Licensed behavioral health professionals are advised to check with their licensing boards as to specific continuing education requirements on medical error prevention. Behavioral health professionals can play an important role in creating a safety culture by providing mental health services for victims of medical error. Victims experience symptoms similar to those experienced by other trauma survivors, such as burdens
Page 34
Book Code: PYFL4024
EliteLearning.com/Psychology
Powered by FlippingBook