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When an adverse event (AE) occurs, it is needed to inform the patient (or his/her family) about what occurred, its foreseeable consequences, and the alternatives to correct it. There are ethical and clinical reasons for disclosing AEs to patients. Spite of, patients expect to be informed, the attitude of professionals is of excessive caution due to fear that disclosing such information will result in a lawsuit. 

Open disclosure can be defined as open communication with a patient (and/or their support person(s)) regarding a patient safety incident that caused significant harm to the patient while receiving medical care/healthcare. In the case of near misses, it is not recommended to inform the patient. (adapted from Clinical Excellence Commission, 2014)”.₁

In practice, only one-quarter of patients receive information after an error that causes them harm. Most healthcare professionals are not properly trained to undertake this communication with a patient. 

The way a show of grief should be exhibited for what has happened (an apology) has also been subject to controversy, especially in without apology laws. In recent years, consensus about how to deal with this communication has grown and help tools have been developed. 

Disclosing an adverse event to a patient is a complex and distressing situation that requires the following:

• adequate organizational framework
• support from the organization and its management
• knowing what to disclose
• communication skills
• ethical commitment 
• a positive attitude that predisposes being open with the patient

Communication requirements after an adverse event

Disclosure after an adverse event involves numerous challenges. One of them is how to put disclosure policies and guidelines into real practice; education and training of the healthcare professionals would help. ₂ On this subject, the steps to ensure an appropriate disclosure will be detailed in section 08 – How to respond to an AE/incident.

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1. Clinical Excellence Commission. Open disclosure Handbook. Sidney: Clinical Excellence Commission; 2014. 
2. Wu AW, McCay L, Levinson W, Iedema R, Wallace G, Boyle DJ, et al. Disclosing adverse events to patients: International norms and trends. J Patient Saf. 2017;13(1):43–9

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Based on Reason’s work, Vincent ₁ developed an organisational accident model which helps to visualize the multiplicity of factors that can be associated to an incident:

Organizational accident model. From Vincent C. Patient Safety. 2nd ed. Singapore: Wiley-Blackwell BMJ Books; 2010.

Considering Vincent’s model, we see that healthcare workers are at the sharp end of the clinical environment, which means that when a major incident occurs one must have a wider approach to understand what has happened. Despite the actions of the individuals could play an important role, their behaviour is influenced by the conditions of their work environment and by broader organisational processes.

At some point of its professional life, a healthcare worker will be involved in an error, which can be a highly stressful experience even when it causes no harm, or it doesn’t reach the patients (near misses). ₂

Instead of looking just for the individual directly involved, one must appraise the broader system and what had led to the mistake/lapse/etc. The factors that influence the clinical practice and that can be considered as error producing conditions ₃ can be summarized as follows:

Framework of contributory factors influencing clinical practice:

Factor types	Contributory influencing factor
Patient factors	Condition (complexity and seriousness) Language and communication Personality and social factors
Task and technology factors	Task design and clarity of structure Availability and use of protocols Availability and accuracy of test results Decision-making aids
Individual (staff) factors	Knowledge and skills Competence Physical and mental health
Team factors	Verbal communication Written communication Supervision and seeking help Team leadership
Work environmental factors	Staffing levels and skills mix Workload and shift patterns Design, availability, and maintenance of equipment Administrative and managerial support Physical environment
Organisational and management factors	Financial resources and constraints Organisational structure Policy, standards, and goals Safety culture and priorities
Institutional context factors	Economic and regulatory context National health service executive Links with external organisations

From Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. Br Med J.1998;316(7138):1154–7.

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1. Vincent C. Patient Safety. 2nd ed. Singapore: Wiley-Blackwell BMJ Books; 2010.
2. Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, et al. The emotional impact
   of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient
   Saf. 2007;33(8):467–76.
3. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical
   medicine. Br Med J. 1998;316(7138):1154–7.

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Patient safety incidents can produce harm to the patients which were over the years subject of numerous studies to access the impact of such occurrences to their lives, as well as it’s causes and the economic burden of the problem.

In recent years it started to be recognized that not only the patients and their families suffer with safety-related problems, so we can consider three types of victims: 

• First victims – the patients that suffer healthcare-associated harm and their families and friends.

• Second victims – Any health care worker, directly or indirectly involved in an unanticipated adverse patient event, unintentional healthcare error, or patient injury and who becomes victimized in thesense that they are also negatively impacted.₁

• Third victims – the healthcare organisations who could suffer loss of reputation, depending on how the situation is handled by the institutional leaders.₂ This issue has been briefly explored so far, so it is a new field for research.

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1. Vanhaecht, K., Seys, D., Russotto, S., Strametz, R., Mira, J., Sigurgeirsdóttir, S., Wu, A. W., Põlluste, K., Popovici, D. G., Sfetcu, R., Kurt, S., & Panella, M. (2022). An Evidence and Consensus-Based Definition of Second Victim: A Strategic Topic in Healthcare Quality, Patient Safety, Person-Centeredness and Human Resource Management. International Journal of Environmental Research and Public Health, 19(24), 1–10. https://doi.org/10.3390/ijerph192416869
2. Denham CR. TRUST: The 5 rights of the second victim. J Patient Saf. 2007;3(2):107–19. 

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The culture of blame or shame experienced after an error does not contribute to learning from these incidents, which limits the possibilities of avoiding the repetition of risky situations for patients. Leadership styles and team dynamics that allow for self-criticism and discussion on how to do things better (psychological safety) also influence the experience of patients and healthcare workers.

The existence of a national patient safety strategy or plan contributes to a better understanding of the experience of patients (their relatives) and professionals involved in safety incidents and in the most risky and complex situations involving a high level of stress. 

The legal framework and in particular professional liability legislation is another key element to be considered. The same applies to options for compensating patients who have suffered a severe adverse event.

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The following video shows Amelia’s story. It’s a fictional story about a young woman who had suffered serious harm healthcare related.

This story will continue to be analysed along our training program but for now it is intended you to watch the video and try to identify the failures across the process of care. In the end of the video, those failures are listed.

This story is an example of an incident whose responsibility can be easily pointed to an individual, but with a careful look, one can identify broader causes behind an error.

You can also identify what are the first, second and third victims in this story.

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The following video presents the response of a nurse to an adverse event.

Use this case to reflect about the measures taken and what can be done to prevent errors after unexpected interruptions which are very frequent in complex settings as healthcare units.

Additional Note:

Bupivacaine (diminutive: bupi) is a local anesthetic indicated for local infiltration, peripheral nerve block, sympathetic nerve block, and epidural and caudal blocks. It should be administrated by qualified clinical staff. The inadvertent intravascular injection of bupivacaine can cause systemic toxicity (cardiac arrest, neurological complications…).

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Communication and Optimal Resolution (CANDOR) is a process that health care institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm. This AHRQ toolkit, based on the CANDOR process, is intended to assist hospitals in implementing communication and optimal resolution programs.

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On this website, you will find a set of tools to reduce the impact that adverse events also have on healthcare professionals (second victims) and on Health Institutions (third victims). Project financed by the Health Research Fund and by FEDER Funds (references PI13 / 0473 and PI13 / 01220), by the Foundation for the Promotion of Health and Biomedical Research of the Valencian Community (reference FISABIO / 2014 / B / 006) and by the Department of Education, Research, Culture and Sports, Generalitat Valenciana (complementary aid, reference ACOMP / 2015/002).

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The Quality & Patient Safety team of the KU Leuven Institute for Healthcare Policy (Belgium) has more than 10 years of experience in research & support systems for healthcare professionals involved in serious adverse events, known as Second Victims. Our findings are published in peer reviewed journals and presented during international meeting. During the COVID-19 pandemic this experience and expertise was used to support our healthcare colleagues during this crisis.

In 1999, the » Institute of Medicine’s report “To Err is Human” estimated that errors cause 44,000 to 98,000 deaths annually in the United States, with a total cost of between $17 and $29 billion each year. Studies show that adverse events occur in one out of ten patients, and 50% of these events are highly preventable. Guilt, fear and frustration are among the best known reactions of the involved professionals. Off course the most important victim is the first victim: the patient & kin. But respectful management of adverse events, for both first and second victims, should be a high priority for hospital management.

10 years ago a white paper of the Institute for Healthcare Improvement stated that the organization has three specific priorities. The first priority is to care for the patient and his or her family members who are the direct victims of the adverse event. The second priority is to care for front-line health care workers involved in or exposed to the event. These individuals can be referred to as “second victims”, a term first introduced by professor Albert Wu in 2000.The third priority is to address the needs of the organization, which can also suffer a potential loss from the incident, becoming a third victim.

Every health care worker can become a second victim: nurses, physicians, pharmacists, social services, physiotherapists,… It is estimated that almost 50% of all health care providers are a second victim at least once in their career! This is a total underestimation and nearly every professional will be involved in adverse events and personal and professional reactions in the aftermath of the event are normal reactions. We may not underestimate the impact of this event and therefor take care of our colleagues. Second victims need to be supported through implementation of support systems on organizational level that result in constructive changes in practice.

The European international leadership regarding this subject lies with the European Research Network on Second and Third Victims. Our team is member of the management team of this network.

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Background

Multiple studies have shown that involvement in medical errors and adverse events can take a significant toll on clinicians. It is estimated that one in seven patients is affected by adverse events, and that as many as half of all clinicians will be involved in a serious adverse event at least once during their career. When a medical error or patient harm occurs, the first priority is to attend to the patient and family members. However, Seys and colleagues and the Institute for Healthcare Improvement have identified three levels at which damage from errors and adverse events occur: the patient, clinicians, and health care organizations. This primer addresses clinician responses to involvement in errors and adverse events, along with support that can be put in place to respond when such involvement occurs.

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Vision Statement

Second Victim Support recognises the impact that a patient safety incident has on the healthcare employee involved. Whilst the patient and their family are always the priority, this website seeks to help ‘Second Victims’ identify the types of support they may need, and signpost them towards help. Our website advocates for a safety culture in healthcare organisations where patient safety incidents are managed in a way that enables learning and improves systems, founded on evidence.

• ‘Second victims’ will find: a place of recognition that you are not alone in your experience; signposting to sources of help; signs to look out for that your health or ability to work is being affected by your experience; and frequently asked questions about the investigation process. Here, healthcare employees share their personal stories of being involved in a patient safety incident, including how some coping mechanisms are more effective than others. We hope this website can reassure you support is available and there is light at the end of the tunnel.
• Managers and other healthcare employees will find: insight into the impact of patient safety incidents on healthcare staff; help to prepare staff to cope with patient safety incidents; signposts to sources of help and guidance to assist you in offering the appropriate level of support for those involved in patient safety incidents.
• Organisations will find: an understanding of the impact of patient safety culture on patient safety incidents and those involved in these; an organisational staff support model and associated approaches aligned to different levels of support, which if available, could prevent those involved in patient safety incidents experiencing lasting consequences: case studies of organisations who have implemented second victim support systems, and a Just Culture Assessment Framework to allow for self-assessment and action to improve organisational patient safety culture.

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Most health care providers adjust well to the multitude of demands encountered during an unexpected or traumatic clinical event. Providers often have strong emotional defenses that carry them through and let them “get the job done.” Yet sometimes the emotional aftershock (or stress reaction) can be difficult. Signs and symptoms of this emotional aftershock may last a few days, a few weeks, a few months, or longer.

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Our forYOU team has been recognized nationally as a leader in supporting our caregivers. We are often contacted by health care providers outside MU Health Care who would like to learn more about our research or use our materials as a model for developing similar programs. Please feel free to use the information and materials on these pages, including our brochures.

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Health care providers face the stress of patient care every hour of every day, and in most cases they handle that stress well. But then there are those times when normal stress blows up into something potentially traumatic–the unexpected loss of a patient; a troubling encounter with a family member; even a run-in with a colleague over care management. At these times, otherwise steady professionals can become psychologically or emotionally devastated “second victims,” who could use prompt support from peers. Most hospitals and other health care facilities, however, do not have a support system in place, and without support, caregivers experience reduced productivity, increased self-doubt and, in some cases, long-term depression.

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