When a mistake is made during a medical procedure, it is the patient and their family that suffers the most. The physical and emotional stress experienced by the victim can be extreme, often changing their lives forever. Yet there are also repercussions for the caregiver who made an unintentional error.
In these cases the healthcare provider is often referred to as "the second victim", a term first used by Albert Wu in 2000. The phrase has since been used to express the need to provide support to healthcare providers following an unintentional error or near-miss patient event.
In 2007, Charles Denham M.D. published "The Five Rights of the Second Victim (T.R.U.S.T.)" and provides senior leaders with guidance on what these individuals need. So what does T.R.U.S.T. mean? Dr. Denham established that individuals deserve Treatment that is just, Respectful and delivered with Understanding and compassion. They deserve Supportive care that is Transparent and the opportunity to contribute to learning after the event occurs. He goes on to state that we must "honor our sacred trust" to both the patients who rely on us to provide care without harm but to also honor our "sacred trust to our caregivers who serve in our hospitals and healthcare organizations".http://nextlevel.gehealthcare.com/safetywebcast/
The first step in providing this support is for healthcare leaders to create a ‘Just Culture’. In 1997, John Reason recognized that a ‘Just Culture’ generates an environment of trust, urging and rewarding individuals for providing vital patient safety knowledge. David Marx's ‘Just Culture’ model recognizes that humans are programmed to make mistakes and because of this, no system can be designed to produce perfect results. According to Marx, there are three degrees of human behavior involved in error occurrence: human error, at-risk behavior, and reckless behavior. Human error and adverse events should be considered outcomes to be measured and monitored with the goal being error reduction, not concealment, and improved systems design.
Healthcare leaders must develop an open, fair and ‘Just Culture’ based on human resource policies that support appropriate action based on these classes of human behavior. Within a ‘Just Culture’, events are not seen as something to be fixed, but as opportunities to improve from both a system risk and behavior risk perspective.
These models, though not new, have not been fully embraced or adopted as necessary to support robust patient safety programs across hospitals. Leaders must embrace these concepts and believe they can make a difference, understand how their organization is positioned, and take steps to institute a ‘Just Culture’, if it isn't in place already. Once this occurs, leadership and healthcare providers will better understand the needs of caregivers involved in a patient safety event and a ‘care for the caregiver’ program can be successfully implemented.
Care for the caregiver starts and ends with complete leadership authentication and participation. Leaders must walk the walk, ensuring that there are clearly defined expectations of what will happen following an unintentional error. Many very talented people have developed tools and algorithms for use by anyone – they are available on the Agency for Healthcare Research and Quality (AHRQ) and the Institute for Healthcare Improvement(IHI) websites, to name just a few.
For more information on this topic, you can also join us for the upcoming webcast titled "The Second Victim" on September 28 at 12-1PM ET featuring Dr. Albert Wu and Jim Conway. Register here.
This initiative reflects GE Healthcare’s on-going commitment to working alongside healthcare professionals globally to find new ways to drive better outcomes and improve the patient’s healthcare experience and safety.