Royal College of Physicians newsletter on Second Victims

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The Royal College of Physicians published the following text as part of the announcement of my talk on October 14 in Dublin:

Kris Vanhaecht will never forget the day more than 20 years ago when as a trainee nurse he mistakenly administered a drug orally rather than in aerosol form. After discovering the error, he spent a sleepless night dreading that an innocuous action might be responsible for patient harm.

“If I can remember that stupid incident from so many years ago during my limited time as a nurse, then what must a doctor remember over a long career?” he muses.

improvementNow aged 42, Dr Vanhaecht, an Associate Professor in Quality Management at Leuven University in Belgium, is an expert on Second Victim Syndrome, which has been defined as affecting healthcare providers who are involved in an unanticipated adverse patient event, medical error and/or a patient-related injury and have become victimised in the sense that the event has traumatised the practitioner.

Prevalence of the syndrome

US research suggests that around 50 % of healthcare workers will suffer from the syndrome at some stage or other during their career but Dr Vanhaecht believes it will likely affect nearly everyone; 50% is a total underestimation.

“There isn’t a single medical doctor, or nurse or pharmacist who won’t experience a patient safety incident at some stage: people say it’s part of the game but this is not a game.”

Since he first began to take a rigorous academic interest in the subject five years ago, he has overseen numerous studies that indicate the prevalence of the syndrome, the persistent failure to acknowledge it and even a tendency to ignore its very existence.

‘Taboo’ subject

“When I talk to my friends who are doctors, pharmacists and nurses, they tell me this subject is still taboo but we owe it to ourselves and especially to our patients to begin talking about it,” he says.   “My logic is simple: if health professionals acknowledge the impact such incidents have made on them, they will be able to take better care of their patients because they certainly will not repeat those same errors – it will create a virtuous loop.”

Various studies have shown the prevalence of mistakes in medical practice but Dr Vanhaecht believes even such alarming figures are actually underestimated.

International research suggests that one in seven patients will experience patient safety incidents and of these, 1 % will die as a result. Dr Vanhaecht asserts the real figures are one in five patients will be confronted with an incident, but not all of the patients and not even all of the involved healthcare professionals are aware of these incidents.

“Patients may not be aware of the error because it doesn’t affect their outcome and doctors may not be aware that they had done anything wrong,” he says.

System failures

Like every human being, healthcare professionals will make mistakes, whether through inattention, distraction, or lack of information. However, research and personal experience suggest that most errors are a result of system failures.

For example, Dr Vanhaecht’s unfortunate scare as a nurse would likely have been averted had his superior specified how the drug should be administered rather than leaving it to her junior’s discretion.

Dr Vanhaecht points out that even the brightest medical specialist must rely on teamwork, which relies on communication and co-ordination.

“This isn’t about a single person who will make a mistake: mistakes can happen in any system, but the system needs to be designed and continuously followed up,” he says.

The remedy is not to ignore incidents but to acknowledge them. Dr Vanhaecht argues for total transparency, including discussion of errors with the affected patient. Although medical negligence claims have been ubiquitous over the past few years, he argues that stonewalling and denial are not the best ways to deal with mistakes.

“U.S. insurance claims have been dropping over the past few years because of greater transparency: when you get to the court, it’s too late,” he argues.

Among other aspects of his presentation to the St Luke’s symposium, Dr Vanhaecht will outline the findings of an upcoming paper by one of his PhD students, Eva Van Gerven, on Second Victim Syndrome. One of her studies of 5,000 subjects concludes that because everyone reacts differently to such incidents, a one-size-fits-all approach to helping individuals deal with the fallout will not work.

“Our studies and discussions among international peers conclude that the impacts are so individual that a peer-support system will have to be implemented but there will never be a standardized algorithm to deal with this problem,” he says.

And, aside from the benefits to healthcare that confronting Second Victim Syndrome will help overcome, Dr Vanhaecht admits a very personal interest in this thorny subject.

“In 20 years’ time or so I may be more in need of hospital care than now and by then we have to have fixed it: we simply have to do something about this.”

Dr Kris Vanhaecht will talk at St Luke’s Symposium at the ‘Quality Improvement- Making Change Happen’ event which takes place on Wednesday, 14 October 2015.

Register now at www.rcpi.ie/stlukes

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