SECOND VICTIM: Background and Treatment – David W. Watson, MD
Second Victim is an area that is now beginning to be recognized for the impact that it has on the quality of healthcare being provided worldwide. The following is a commonly used definition: “Healthcare providers who are involved in an unanticipated adverse patient event, medical error and/or patient related injury and become victimized in the sense that the provider is traumatized by the event.” The initial reaction to the event is situational anxiety. If not recognized, addressed and resolved, it can lead to post traumatic stress disorder.
In the past healthcare providers, especially physicians, have entered their practices with the attitude they don’t make mistakes, and if they do, they suck up the consequences and move on. This attitude has be reinforced by the malpractice litigation that has been attached to medical errors. Talking about such situations in the past has been frown upon by fellow physicians and risk managers.
Dr. Albert Wu, who directs the Center Health Services and Outcome Research at Johns Hopkins Medical Center, confirmed by his work in the 1980s as a medical resident and in 1990s as a practicing physician that “every practicing physician has either harmed a patient or certainly been involved in the care of a patient that has been harmed.” An NIH study in 2009 found that two-thirds of providers involved in a case where a patient was harmed experienced extreme sadness and difficulty concentrating in the wake of harming a patient.
Around 9:30 AM on September 14, 2010, Kim Hiatt, a nurse at Seattle Children’s Hospital with over 24 years of experience, took a verbal order for IV calcium chloride. She was caring for a frail 9 month old infant. Kim did the math in her head: thinking there were 10 mg/ml, she drew up 14 ml and administered it IV after checking the patients name band, the date and time and the size of the dose. About lunchtime, one of the rounding doctors notice that the infant’s heart rate had increased dramatically and he ordered lab work. The infant’s calcium level was quite elevated. She reviewed her math with a co-worker who pointed out the medication came in a 100 mg/ml dose. She realized her mistake.
Kim immediately documented her error in the chart. Kim’s supervisor read the note and immediately found Kim, escorted her to her car and told her to leave the campus. She was isolated from her patient, her co-workers, and the hospital where she had worked. The hospital fired her. She was put on probation for four years by the Washington Department of Health. She tried in vain to find work for several months. On April, 3, 2011 Kim hanged herself in her basement leaving a husband, grown daughter and teenage son behind.
Kim was indeed a Second Victim. The infant was of course the primary victim. The tertiary victims were many including the family of the infant, Kim’s family and the hospital. The Culture at Seattle Children’s Hospital was punitive. In 1999, the paper To Err is Human was published. This paper verified that error in healthcare are inevitable. It has been a challenge for the healthcare community to change the culture. It take a just culture to realize that we need to learn from our mistakes and near misses as we work toward a goal of “zero harm.”
Johns Hopkins has been a leader in this transformation to a just culture. In January of 2001, an 18 month old infant, Josie King, was admitted to the Pediatric ICU with severe burns to a large portion of her body. After a three week stay she appeared to be improving and ready for discharge; she suffered a cardiac arrest and died. Blame was cast on the staff in the Pediatric ICU. Many staff left. The Ped’s ICU and floor were not considered a staff friendly place to work. A review of the death showed that Josie died as a result of her dehydration and sepsis.
One of the staff pediatricians, Dr. Lauren Bogue, convinced Dr. George Dover, director of the Johns Hopkins Children’s Center, to have a meeting with the King family and disclosed what really happened. A settlement was reached with the King family. The proceeds of the settlement were placed in a trust dedicated to improving patient care and addressing the way the hospital dealt with staff who make errors. Many patient safety initiatives followed. CUSP (Comprehensive Unit-based Safety Program) was one of the first robust process based improvement tool put in place at Hopkins. This tool gained national and international recognition as changing the way healthcare was delivered.
The term Second Victim was coined by Dr. Wu in 1999. Dr. Wu and his group at Hopkins have continued to work on the Second Victim Issue. This work has developed the RISE (Resilience In Stressful Events) Program specifically designed to support Second Victims. Their work and that of other groups have verified that only 15% of the time does the adverse events involve a medical error. Healthcare is an environment in which stressful and unpredictable event occur as part of the natural process. Bad trauma, delivery of very pre-term babies, and caring for the very ill in the ICU are situations that confront healthcare workers every day.
We often forget about the primary victim, especially if they survive the event. One such instance is that of Linda Kenney. Linda had worked in healthcare as a clerk. She had had several orthopedic procedures to correct the club feet she was born with. In 1999 she was scheduled for another such procedure, having already undergone 20 or so procedures. She was to receive a ankle block for the procedure. During the process of placing the block, the anesthesiologist inadvertently injected the Marcaine into a vein. Linda suffered a cardiac arrest. She did not respond to conventional CPR. The event happened in an operating suite that had cardio-pulmonary bypass capability and she was placed on bypass and survived. She woke up several days later intubated in the ICU. She slowly recovered and returned to a functional life but could not get an explanation as to what happened other that “it was an allergic reaction to the anesthetic.”
She was finally contacted by DR. Rick van Pelt, the anesthesiologist who administered the block. He explained what had happened and conveyed his sadness and concern over the event. This concern grew into a passion for both to find a way to support all the victims of an adverse event. In 2001, they formed the Medically Induced Trauma Support Services (MITSS). It has grown into an organization that is dedicated to supporting primary, secondary and tertiary victims of adverse medical events. They support multiple efforts to improve patient safety as well as recognizing and learning from medical errors.
A real pioneer in the area of Second Victim recognition and research has been Sue Scott, RN at the University of Missouri Health Center. Her program is very proactive in the recognition of Second Victims. She has trained over 200 volunteers at the University of Missouri Healthcare Center to recognize when an adverse patient care event is occurring. A volunteer then comes to talk with identified Second Victims to see how they are feeling and copping with the reactions to the situation in which they have just been involved. If they need further help in resolving their issues after the initial visit, they are referred for special help to a forensic nurse, psychiatrist, psychologist or clergyman. Healthcare worker are encouraged not to return to work until they feel 100% ready to do so.
The driving force behind the Missouri program is ‘Tony’s Story.’ Tony was an RN working in the ICU on a Friday night in 2008. He was giving procedural sedation to a patient for a routine procedure. The patient suffered an unexpected cardiac arrest. Resuscitation efforts were unsuccessful. Risk management at the hospital reviewed the case and could find no evidence of a medical error. However, on Monday Tony called in and said he would not be able to report for scheduled shift. He was distraught, nauseated and had been unable to sleep over the weekend. He had continued to replay the events of Friday night and believe he had missed something that may have changed the outcome. This case caught Sue Scott’s attention and raised the question how often healthcare providers involved in an adverse event are compromised with their ability to return to work and fully give their best. Her statistics have confirmed that over 85% of the time adverse patient care events do not involve a medical error.
The healthcare providers who initially become a Second Victim and are not immediately supported through their situational anxiety may have varied responses. These may include but are not limited to: a feeling of isolation, extreme fatigue, sleep disturbances, a physiological stress response, loss of self confidence, inability to concentrate, grief, remorse, feelings of shame, inadequacy and anxiety. They may have frequent feeling of self doubt and have a sense of inadequacy to carry out their duties in the workplace.
The healthcare providers will go through phases as the response continues to progress and they begin to picture in their minds they are part of an enduring inquisition. If they don’t receive help at this point, they will most likely develop Post Traumatic Stress Disorder. They may choose to leave the department, leave the profession entirely, and in the rare instance, commit suicide. PSDT is an overwhelming problem for our Veterans; 22 commit suicide each day. Other healthcare providers just “hang in there.”
An organized program of support for these victims is the best chance for abating the effects of the adverse event. This program provides resilience for the organization which is the ability to recover from misfortune of change. This program should support patients and families as well.
As a healthcare community, we need to address how we will approach the Second Victim issue. As an organization develops robust processes and moves along their journey to high reliability and adopts a just culture, transition to a program of support for Second Victims will be much easier to implement. Both Johns Hopkins RISE program and the forYou program at the University of Missouri are good examples of such programs. In 2005 the Congress passed the Patient Safety and Quality Improvement Act. This legislation allows organizations to form Patient Safety Organization (PSO) to review medical errors as a learning experience to improve the safety of healthcare delivery. So far the immunity from discovery for use in medical-legal proceeding has been upheld in the courts.
It is important that organizations start their own programs. If they do not, it is my fear that patient advocacy groups will pressure legislatures to draft laws that define the process. This will most likely not be the best solution.
In conclusion, work in the field of the Second Victim clearly shows that early recognition of the situation and support of the Second Victims are keys. Support of the individual is a separate process than that of looking at the particulars of the event. These should be addressed by the PSO as part of the safety improvement process. As a healthcare community we take great care of our patients. It’s time for us to take better care of ourselves.