The Aftermath of Medical Errors: Supporting Our Second Victim Colleagues Hanan H. Edrees, DrPH, MHSA

Transcription

1 The Aftermath of Medical Errors: Supporting Our Second Victim Colleagues Hanan H. Edrees, DrPH, MHSA Associate Faculty, Johns Hopkins Bloomberg School of Public Health, USA Manager, Ministry of National Guard Health Affairs, Kingdom of Saudi Arabia May 2017

2 Kimberly Hiatt Nurse for 24 years Seattle Children s Hospital Medication error (September 2010): child 5 mo/patient dies dispensed 1.4 grams of CaCl instead of 140 milligrams Dismissed from job

3 What about.? What about the doctor who wrote this order? What about the pharmacist that approved this order? What about the process/system that set them up?

4 Kimberly Hiatt commits suicide after 10 months after the event

5 Second Victims Second victims: Healthcare providers who are involved with a patient-related adverse event or medical error, and as a result, they experience emotional and sometimes physical distress First victim: patients and families Term coined by Dr. Albert Wu: 2000 Second victims often Feel personally responsible for the outcome Feel as though they have failed the patient Second guess their clinical skills and knowledge Signs & symptoms Similar to Post Traumatic Stress Disorder symptoms Physical and psychological distress Negative emotional responses Impaired performance Wu, A. (2000). Medical Error: The Second Victim. British Medical Journal

6 Signs & Symptoms of Second Victims Short term: shock helplessness worry and depression guilt and inadequacy anger poor concentration and memory intrusive thoughts and nightmares sleep disturbance physical symptoms social avoidance Long term: (Indistinguishable from posttraumatic stress disorder) recurrent experience of the event avoidance emotional numbing chronic signs of hyper-arousal including sleep disturbance, irritability, poor concentration, diminished memory withdrawal and depression social functioning can be impaired, and personal and professional relationships can suffer

7 Burnout Symptoms Procrastination Chronic fatigue Cynicism Tardiness Anhedonia Pessimism Diminished future outlook Loss of life satisfaction

8 Impact of Error on Second Victims and the Organization 1. Impact on the individual Clinical conditions o Post-Traumatic Stress Disorder (> 3 months) o Acute Stress Reaction (up to 1 month) Stress Reactions & Distress 1. Impact on the organization and healthcare team 2. Management & treatment of psychological care Continuum of Care

9 Prevalence of Second Victims Study 1 Study 2 Study 3 Study 4 Prevalence 10.4% 1 30% % % 4 Population otolaryngologists sample of medical students, physicians, and nurses physicians, nurses, and pharmacists, and other healthcare professionals physicians, nurses, and pharmacists, and other healthcare professionals Feelings/sympto ms described an error they were involved in during the past 6 months personal problems related to anxiety, depression, and challenges in their ability to provide care during the past 12 months the error had a moderately severe or severe harmful effect on their personal lives experienced problems, such as anxiety, depression, or concern about their ability to perform their job 1 Lander, L. I., Connor, J. A., Shah, R. K., Kentala, E., Healy, G. B., & Roberson, D.W. (2006). Otolaryngologists responses to errors and adverse events. Laryngoscope,116, Scott, SD; Hirschinger, LE; Cox, K; et al. (2010). Caring for Our Own: Deploying A Systemwide Second Victim Rapid Response Team. Joint Commission Journal Quality Patient Safety, 36: Wolf, Z. R., Serembus, J. F., Smetzer, J., Cohen, H., & Cohen, M. (2000). Responses and concerns of healthcare providers to medication errors. Clinical Nurse Specialist,14: Edrees H, Paine LA, Feroli ER, & Wu A (2011). Healthcare workers as second victims of medical errors. Polish Archives of Internal 9 Medicine.

10 Limited studies on second victims Limited literature Prevalence of second victims: 10.4% % Studies on concept of second victims: Switzerland, Belgium, Denmark, Sweden, Italy, the United Kingdom, and the United States Descriptions of organizational support programs Little documentation of the steps involved in their development Limited resources for evaluating the feasibility and effectiveness of these programs

11 Natural History of the Second Victim (1) Initial response to incident (2) Peer response (3) Investigation (4) Complaint system/ Malpractice suit

12 Second Victim Trajectory of Recovery Scott S, et al (2009). The natural history of recovery for the healthcare provider second victim after adverse patient events. BMJ Qual Saf Health Care.

13 Doing better but feeling worse Under the Bus Good disclosure but poor follow through At expense of the feelings of health care workers? Courtesy of Dr Albert Wu

14 Making the case for peer support.

15 Assessing the Need for Second Victim Support Objective: To assess patient safety leaders perspectives on the concept of second victims and support programs Methods: In-depth, semi-structured interviews 43 patient safety representatives from 38 acute hospitals in Maryland Descriptive statistics were generated for hospital and participant characteristics Response Rate: 83%

16 PART I: Does One Size Fit All? Assessing Need for Organizational Second Victim Support Programs Objectives: To assess the extent of the second victim problem, To determine the availability of emotional support services, and To assess the need for organizational support programs. Results: All participants reported that they and their executives were aware of the second victim problem. All participants believed that hospitals should offer organizational support. There continues to be a stigma associated with speaking up and accessing support if it were offered. Edrees H & Wu A. (2016). Does One Size Fit All? Assessing the Need for Organizational Second Victim Support Programs [accepted: Journal of Patient Safety-July 2016]

17 Part II: Do Hospitals Support Second Victims? Collective Insights from Patient Safety Leaders Objectives: To describe the extent to which organizational support for second victims is perceived as desirable, and To identify existing support programs Results: All of the hospitals offered Employee Assistance Programs to their employees, but there were gaps in the services Moreover, there are no valid measures in place to assess the effectiveness of these services. Participants identified a need for peer support, both for the second victim and for individuals who provide that support. Approximately 6 Maryland hospitals offer a second victim support program, with differences in structure, accessibility, and outcomes. Edrees H, Morlock L, Wu A. (2017). Do Maryland Hospitals Support Second Victims: Collective Insights from Patient Safety Leaders in Maryland Hospitals [accepted: The Joint Commission Journal on Quality and Patient Safety]

18 Organizations that care for the caregiver Support programs for hospital workforce Medically Induced Trauma Support Services (MITSS) University of Missouri: foryou program Kaiser Permanente Program Boston Children s Hospital: The Office of Clinician Support (OCS) Brigham and Women s Hospital: The Center for Professionalism and Peer Support (CPPS) Johns Hopkins Hospital: Resilience In Stressful Events (RISE) Program Support for other psychological trauma Psychological First Aid (PFA) & RAPID-PFA Critical Incidence Stress Management (CISM) Support programs for the military

19 Schrøder K, Jørgensen JS, Lamont RF & Hvidt NC. (2016). Blame and guilt a mixed methods study of obstetricians' and midwives' experiences and existential considerations after involvement in traumatic childbirth. Acta obstetricia et gynecologica Scandinavica. The Buddy Study Odense University Hospital & Department of Public Health Department of Obstetrics and Gynecology Department of Oncology Dr. Katja Schrøder kschroeder@health.sdu.dk Schrøder K, la Cour K, Jørgensen JS, Lamont RF, & Hvidt NC. (2017). Guilt without fault: A qualitative study into the ethics of forgiveness after traumatic childbirth. Social Science & Medicine.

20 Implementing a Second Victim Peer Support Structure at The Johns Hopkins Hospital

21 RISE at The Johns Hopkins Hospital 1,075-licensed bed, urban, academic medical center in the state of Maryland, USA Medical errors and adverse patientrelated events are inevitable reported, investigated and debriefed with staff Several events occurred Hospital leadership created second victim taskforce to establish an organizational support program/service for second victims

22 Our Current Infrastructure Patient Safety & Quality Departments Risk Management Employee Assistance Program Chaplain Services Occupational Health Human Resources.. no clear pathway to help second victims cope with their emotions

23 Organizational Assessment Organizational survey was administered at 2 nd Annual Johns Hopkins Patient Safety Summit in June 2010 Results (n=140): Two-thirds reported experiencing emotional distress following an unanticipated adverse event More than half had reached out for support from a peer or colleague The need for a peer support program to benefit second victims in the Hospital Edrees HH, Paine LA, Feroli ER, Wu AW. (2011). Health care workers as second victims of medical errors. Pol Arch Med Wewn, 121(4):

24 RISE Team: Resiliency In Stressful Events Mission: To provide timely support to employees who encounter stressful, patient-related events Objectives: 1. Increase awareness of the second victim phenomenon 2. Provide multi-disciplinary, one-to-one or group, peer support in a non-judgmental environment 3. Equip managers & employees with healthy coping strategies to promote well-being 4. Reassure & guide employees to continue thriving in their role

25 Developing the RISE program Phase 1: Developing the RISE Team Phase 2: Recruiting and training Peer Responders Phase 3: Launching RISE pilot in Department of Pediatrics Phase 4: Launching RISE hospital-wide Edrees H, Connors C, Paine LA, Norvell M, Taylor H, & Wu AW. (2016). Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. BMJ Open.

26 Contacting RISE Event happens Second victim pages RISE Referrals: self, manager, legal/risk management, peer RISE page received by Peer Responder Peer Responder meets with second victim Peer Responder activates debriefing with RISE team to discuss de-identified interaction with second victim - learning opportunity for RISE team - support for the Peer Responder

27 What does RISE do? Supportive and attentive conversation Facilitate resources within the hospital that might be helpful Provide 24/7 available support One to one or group support

28 What does RISE NOT do? We are not counselors or psychiatrists We do not investigate or report back to supervisors We do not problem solve We do not fix employment problems

29 Training Peer Responders 1. Psychological First Aid (PFA) used to describe early interventions to address emotional distress goals of PFA are similar to that of physical first aid stabilize, mitigate psychological distress, facilitate recovery, and promote access to additional resource 2. Peer Responder meetings Educational sessions: lecture presentations, Role-play, Video excerpts, Handouts, Narratives 3. Debriefings

30 Continuum of Care Psych First Aid** Crisis Intervention Counseling Psychotropic Meds & Psychotherapy Physical First Aid Basic Life Support Advanced Life Support Medicine & Surgery ** stabilize psychological and behavioral functioning, mitigate psychological distress and dysfunction, facilitate recovery and return to adaptive psychological and behavioral functioning, and promote access to additional resources

31 Financial Impact of Implementing RISE OBJECTIVE : To conduct an economic evaluation on cost-benefit of RISE for nursing staff who used the program between 2015 & 2016 METHODS: The cost of running RISE, nurse turnover, and nurse time off Data on costs and probabilities of quitting or taking time off with or without the RISE program Net monetary benefit and budget impact of RISE RESULTS: Net monetary benefit savings of US $22, per nurse who initiated a RISE call. The budget impact analysis revealed that a hospital could save US $1.81 million each year from the RISE program. Moran, D et al (2017). Cost-Benefit Analysis of a Support Program for Nursing Staff. Journal of Patient Safety.

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34 How can your organization participate Acknowledge the problem of the second victim When errors happen, encourage staff to be involved in system changes that will mitigate future errors Hold debriefings and offer training, formal organizational support and coping strategies for individuals Develop multidisciplinary second victim support programs that align with existing organizational infrastructure Communicate and collaborate with institutions that have existing or emerging programs

35 Things to say and not to say to colleagues after an adverse event Edrees H, et al (2011). Healthcare workers as second victims of medical errors. Polish Archives of Internal Medicine.

36 A Medical Oncologist s Poetry: Dr. Jazieh Hospital Rounds I walked into your room and here you were Lying down there yellow skin and swollen face You peeped at me with those jaundiced eyes You were still gracious as I knew you all the times We exchanged comforting looks, I needed them too as much as you did Your weakened voice declared that you are still there: You did your best, Doc! You are still my favorite I felt my inside shivering How can I be empathetic yet not cry? Do not push more buttons, Please so they do not flood the eyes As it may not be good for the young doctors around watching the drama unfold Watching how someone would die yet be gracefully thankful How the dying comfort those who stay behind How a man who is supposed to heal let his patient say good bye How the partners in such a struggle depart from each other at last O Donnell, JF. A Medical Oncologist s Poetry: Abdul-Rahman Jazieh, MD, MPH (2005). Journal of Cancer Education, 20(4).

37 Acknowledgements Odense University Hospital & The University of Southern Denmark Dr. Kim Brixen, Dr. Kirsten Kyvik, & Dr. Katja Schrøder Johns Hopkins RISE Program Dr. Albert Wu, Dr. Lori Paine, Ms. Cheryl Connors, & Mr. Matt Norvell Dr. Henry Taylor Dr. George Everly Johns Hopkins RISE Peer Responders Johns Hopkins Second Victim Advisory Board Maryland Patient Safety Center

38 Hanan H. Edrees, DrPH, MHSA Associate Faculty, Johns Hopkins University

39 Additional Slides

40 Scott Three-Tiered Interventional Model of Second Victim Support Scott S, et al (2010).Caring for Our Own: Deploying a Systemwide Second Victim Rapid Response Team. The Joint Commission Journal on Quality and Patient Safety

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42 Characteristics of RISE Calls (n=80) Description of calls: death of a patient (45%), involved in adverse event (21%), other: difficult situations, burnout, staff assault, conflicts, etc.

43 PFA PFA was co-developed in 2006 by the National Center for Post Traumatic Stress Disorder, a division of the United States Department of Veterans Affairs, and the National Child Traumatic Stress Network as a technique used to assist individuals in the immediate aftermath of a disaster and to reduce the occurrence of PTSD.