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Content Index

  • 01. Ambition (2 Articles)

    The overall aim of this COST Action 19113 is to facilitate discussion and share scientific knowledge, perspectives, and best practices in healthcare institutions to implement joint efforts to support second victims for benefit patients safety. Also, we pursue to introduce an open dialogue and discussion among stakeholders about the consequences of the second victimsphenomenon based on a cross-national collaboration that integrates different disciplines and approaches.

    These materials outlinegeneral information for a better understanding of the second victims phenomenon and the steps required to launch and maintain a streamlined, centralized, and peer review protected Peer Support Program at healthcare institutions (hospitals, social and primary care institutions).

  • 03. Essential of patient safety (4 Articles)

    Patient safety as a priority in Europe. The World Health Organization’s (WHO) World Alliance for Patient Safety (2005) defines patient safety as ‘freedom for a patient from unnecessary harm or potential harm associated with healthcare’. While health care has become more effective, it has also become more complex, and there are consequently more risks to patients. Patient safety is currently a priority in all European healthcare systems and beyond.

    In European countries, significant improvements to provide safer care for patients have been introduced in health systems seeking to ensure that procedures and treatments are being performed correctly and in a timely and effective way. Although the organisation of health systems and the delivery of healthcare remain a national competence, the EU plays an increasingly important complementary and supporting role in health and the impact of its actions on policies, healthcare delivery, and patient safety is highly significant. The EU has made legislation, recommendations, and funded projects to assure patient safety and mutual sharing and learning between Member States.

  • 04. Healthcare workers make mistakes (1 Article)

    It includes a description of what knowledge is about clinical errors and a recognition of clinical errors and their impact of patients, professional and the healthcare system as a whole.

  • 05. The experience of suffer an adverse event (2 Articles)

    Patients have first-hand experience of harm and have needs that must be addressed. In this case we know what they need:

    1. Medical and psychological care for recovery
    2. To know what has happened and what can happen from now on.
    3. Know what measures are being taken to ensure that it does not happen again.
    4. Receive an apology

     

     

  • 06. Barriers and gaps to be considered (2 Articles)

    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.

     

     

  • 07. Patient Safety Culture (1 Article)

    Patient Safety culture has been defined as the set of values, attitudes, perceptions, beliefs, skills and behavioural patterns that at the individual and group level determine compliance with quality and safety procedures, leadership styles and capacity to manage the risks to patients associated with healthcare. Safety culture is directly related to the outcome of the healthcare intervention and is linked to organisational factors, leadership styles, composition and operational capacity and decision-making by clinical teams.

     

  • 08. Psychological safety (1 Article)

    Psychological safety refers to the shared belief that a team can deal with complex challenges when there is an atmosphere of mutual respect and trust. Thus, safer care is provided when the causes and ways to avoid clinical errors can be discussed and analyzed without fear of criticism or sanctions.

    The term “speaking up” is used to refer to the assertive communication of quality and patient safety concerns by a team member through information, questions, or opinions in situations where a healthcare professional neglects, forgets or even ignores clinical guidelines to prevent patient harm.

    In a recent study in Austria, 32.3% of surveyed physicians and nurses said they had not expressed concerns regarding patient safety and 41.6% had kept ideas to themselves that could have improved patient safety in their unit. An equivalent study with medical students revealed that 59% had not felt able to speak up in a critical situation.

     

  • 09. How to respond to an AEs/incidents (2 Articles)

    It should be considered that while adverse events are the flip side of the patient safety coin, the management of the risks inherent in healthcare is the desirable goal and therefore an integral part of good clinical practice.

    This opens the way for the concept of resilience in healthcare organisations, understood as the degree to which a system prevents, detects, mitigates or ameliorates hazards or incidents, enabling an organisation to “recover” as quickly as possible to its original ability to perform care functions after harm has occurred. Achieving this requires, as previously stated, an appropriate environment.

     

  • 10. The Second Victim phenomenon (9 Articles)

    When an adverse event occurs, there is a domino effect with healthcare professionals (named second victims of these events) suffering from the knowledge of having harmed their patients (first victims).

    A second victim has been defined as “a health care provider involved in an unanticipated adverse patient event, medical error and/or a patient related-injury who become victimised in the sense that the provider is traumatised by the event”.

     

    Studies of the frequency of healthcare provider errors underline that more than 86% of healthcare professionals recognize an unintentional clinical error during their professional career, and 58% of them have reported serious adverse events; these emotional disturbances are usually more intense among providers females than males.

    European studies indicate that around 72% of health care providers in hospitals and 62% in primary care reported having suffered the second victim experience in the previous five years. An alarming 86% of these professionals reported that they received no counselling and 56% no institutional support. Of these, 24% required time off work and 25% transferred to a different department/centre.

    Frequently, second victims feel personally responsible for the unexpected patient outcomes and suffer doubts about their clinical skills and knowledge base. Also, they are afraid of the legal, economic, and professional consequences. The second victim phenomenon increases the likelihood of further errors and suboptimal care as consequences of emotional disturbances in the hours/days following the occurrence of an adverse event. Therefore, if not alleviated or treated, the second victim phenomenon can harm the emotional and physical health of care providers and subsequently compromise patient safety.

     

    Evidence-based interventions to address the SV phenomenon increase patient safety by reducing AEs; promote staff and team wellbeing, engagement morale and retention, public engagement, and trust in healthcare; and reduce the costs of financial compensation.

     

     

  • 11. Why this is key for patient safety (6 Articles)

    Although all people make errors, they do not all have the same meaning or transcendence. Clinical errors have a very different importance because the health (and sometimes the life) of patients is at stake.

    Healthcare activity in hospitals and social & primary care centres is not risk-free and sometimes, unexpectedly, a patient may suffer some kind of harm in the course of the care he or she is receiving. The idea that only “bad” professionals make errors, precisely because of their ineptitude, is false. It would be fantastic if it were true, because it would imply that, with a simple solution, separating these “bad professionals”, we would solve the problem of patient safety. But the reality is much more complex and all professionals, even those with an excellent track record, can make an error with serious or fatal consequences.

    The organizational culture that shares the idea that errors are occasional and the result of the inexperience of a few professionals, only leads to hide or disguise reality and, ultimately, to subject patients to a greater risk. Healthcare organizations that act in this way lose the opportunity to prevent future safety incidents and also put at risk the legal certainty, clinical judgement capacity and working wellbeing of their professionals.

     

  • 12. What is being done in Europe (2 Articles)

    Now and since the past two decades different interventions are being implemented in Europe to enhance the resilience of healthcare professionals in stressful situations for addressing this problem. However, the number of proved interventions in progress is scarce.

    The worries and shame experimented with these events are some of the barriers that make it difficult to tackle this phenomenon, as well as preventing from engaging more actively in putting up barriers, speaking up or reporting adverse events, finally the patients are the biggest affected. In addition to very different legal schemes coexist, barriers to speak-up about errors, mistakes, and mishaps and blame and shame cultures.

     

  • 13. How to introduce a change. Lessons learned (29 Articles)

    Material Prepared by Lisa Larasik as a product of the VIRTUAL NETWORKING SUPPORT (VNS) grant awarded by COST Association in the framework of COST Action 19113.

  • 15. Other sources of information (9 Articles)

70 Articles