Second Victims - the Nurse that Makes a Mistake

The term second victim refers to the nurse, provider or another medical professional that makes a mistake that either harms or had the potential to harm a patient. Here is how one hospital deals with this issue.

Second Victims - the Nurse that Makes a Mistake

Nationwide Children's Hospital, located in Columbus, Ohio is a nationally ranked pediatric care center which spans 68 facilities caring for the sickest children in the state. While they care for children, they also care for their staff.

The Agency for Healthcare Research and Quality describes second victims of medical errors: "While the focus of the patient safety field has mostly been on improving systems of care, such systems include real people, and safety events may take an emotional toll. Frequently, clinicians review medical errors and understand what has unfolded, reacting with appropriate sadness and concern. Such errors occasionally result in an intense period of professional and personal anguish, even among the "strongest" caregivers."

So, how do we care for the second victims?

AN recently interviewed Jenna Merandi, PharmD, MS who is the Medication Safety Coordinator; Director, at Nationwide Children's Hospital. Her educational credentials include: PharmD, West Virginia University School of Pharmacy and an MS in Health-System Pharmacy Administration, The Ohio State University.

1. The nursing community has heard of second victims committing suicide. (Kim Hiatt, RN). What happens if an employee is terminated due to an error? Where can they go for support?

Generally speaking, we do not terminate an employee for one mistake as everyone is human and we can all make errors. Each situation is evaluated on its own merits to determine the appropriate course of action. For any employee who makes an error, they can reach out to their supervisor, peer supporter (one is available in every department), or Matrix services for support. Very difficult situations are also presented through our Schwartz rounds.

2. What measures are in place to ensure that what is discussed in the peer to peer discussions is not discoverable if a lawsuit ensues?

We train our peer supporters to focus on providing emotional support to individuals, not discussing the details of an event. No information is recorded or documented that relates to the event itself. The main goal of peer support is to provide one on one assurance to second victims and support them emotionally.

3. Can a second victim utilize EAP at the same time as this program?

Yes, EAP is actually a part of our program. We utilize the "Scott Three Tiered Interventional Model of Support" which consists of:

Tier 1 support - could be provided by a manager, supervisor or colleague to recognize the signs and symptoms of a second victim and provide reassurance to that individual.

Tier 2 support - consists of trained peer supporter who has been trained with the basic skills of responding to second victims and who provides one on one interventions and potential team debriefings

Tier 3 support - our professional resources which include Employee Assistance Program (EAP), Clinical Psychologist, Social Work and Pastoral Care

Second victims who need additional help beyond that of a peer supporter can utilize our EAP.

4. Has there been culture-wide education? By that I mean, when a nurse/provider/someone else makes a mistake, one of the common phrases heard is "well that could never happen to me because I'm too careful." Its the whole system that needs to change.

Yes, there has been culture-wide education both related to Zero Hero and our peer support program and as it relates to safety in our organization. The safety culture is incredible at Nationwide Children's as frontline staff feels comfortable reporting adverse events and working to try and prevent harm. We have a "just culture" at our institution which means there is shared accountability and follow up actions match the behaviors regardless of who is involved and what the outcome is.

5. Are there any additional measures in place in case of the death of a patient due to an error? Is critical incident stress debriefing used at all?

Yes, we have a Critical Incident Stress Management (CISM) team and debriefings could be conducted for larger group intervention (that beyond the role of peer supporter).

Second victims are often forgotten in the scheme of an error. Nationwide Children's Hospital is at the forefront of programs designed to decrease the trauma of being a second victim.

What is your facility doing to help the second victim? Please share.

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traumaRUs

About traumaRUs, MSN, APRN

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Specializes in Tele, ICU, Staff Development.

It's so important to support second victims.

I'll never forget a nurse I worked with who made a Fatal Error. I don't think she ever recovered, and it was all very hush-hush.

Thanks for sharing how one hospital handles this.

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Second victim: I was immediately suicidal and fell apart in my best friend's living room. She is a "retired" nurse. I was hospitalized for a week and remained in therapy for almost a year. The event was only one factor in my decision to retire.

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Specializes in CCU, SICU, CVSICU, Precepting & Teaching.

We've all made errors -- some of us are fortunate enough to have caught our own error (or had it caught by others) before there was harm to the patient. I've been in both positions. I have also been involved in a sentinel event -- one of a series of health care team members who overlooked a critical lab value until it was too late. I was the last one in the chain . . . closest to the outcome. Although it was many years ago, I still wake up in the middle of the night, heart pounding and horrified once again. For months after the event -- more like two years, I would wake up in anguish over my failure to catch that lab value and intervene. When the patient's status changed, I attributed it to the reasons outlined by her medical team. Had I noticed that one lab result, I would have known better. Had I noticed it in a timely fashion, I could have changed the outcome. I know that I'm not the ONLY person who should have noticed and could have changed the outcome -- my charge nurse, the intern, the resident, the fellow, the attending and the consulting teams could have and should have noticed as well, but didn't. Nevertheless, I am the one who "took the heat" for it because I was the one at the bedside. And for years I beat myself up over it.

I kept my job, but it was rough for a long time. There were investigations into the event, investigations into the investigations and investigations of my state of mind, critical thinking skills, knowledge base and fitness for my position. Those endless interviews with risk management, nursing management, the medical team, etc. were difficult to endure but hopefully necessary to the process of ensuring that a thing like that never happens again. After a few years, I didn't think of that incident every time I walked past that patient room but there were whispers in the break room that would suddenly stop when I entered. A few "well-meaning" folks went out of their way to "tell you what people are saying about you behind your back." That still happens from time to time.

Years after the event, a nurse practitioner who was one in the chain of folks who ALSO should have noticed sought me out because she was leaving the hospital and wanted to talk to me first. She told me that in M & M Rounds, the attendings, the fellows, the residents, the interns and the NPs involved in the patient's care blamed the entire event on *my* failure to notice that lab result. But one nurse practitioner stood up and said "If I was operating in the same conditions as Ruby with the same access to information and the same support as she had, I would not have done anything differently than she did." I needed to hear that. Then she told me that some of those most vociferous in blaming me for the entire chain of failures were also beating themselves up about their part in the failure -- including herself. I needed to hear that, too.

A few years after the event, researchers came to our unit to discuss their ideas for a study of what would be most helpful to secondary victims of a medical event. It was the first time I'd heard the term. I'm glad that more research is being done, more help is being offered to those who have found themselves involved in medical errors and sentinel events. I wish that there had been something available to me in the time that I most desparately needed it.

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Specializes in Varied.
She told me that in M & M Rounds, the attendings, the fellows, the residents, the interns and the NPs involved in the patient's care blamed the entire event on *my* failure to notice that lab result. But one nurse practitioner stood up and said "If I was operating in the same conditions as Ruby with the same access to information and the same support as she had, I would not have done anything differently than she did." I needed to hear that. Then she told me that some of those most vociferous in blaming me for the entire chain of failures were also beating themselves up about their part in the failure -- including herself. I needed to hear that, too.

While there is some blame to be had for yourself, it's crucial to point out that several people missed the opportunity to intervene. You are only one person, only capable to be responsible for yourself! Thank you for sharing your experience!

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Specializes in PeriOp, ICU, PICU, NICU.

My place of employment crucifies second victims. One error and you are immediately asked to leave and they will contact you. Then you have to come in several times and talk to charge nurse, assistant manager, manager, director, risk management and whoever else. Then, once allowed to come back to work (usually after a week after), you have to report to a panel of nurses in what people call the room of shame. The panel is comprised of mostly managers of different departments and staff nurses. They basically have you tell your story, what you could have done better, what you will do and then you are basically colored a target on your back. Then, in morning report and unit staff meeting they make you retell your story. They make you put together some kind of poster with 'educational' session and once again the walk of shame in front of the entire unit.

I have never seen any nurse be right after that. They withdraw, have PTSD, issues at home or just grieve forever. Management makes an example out of them forever. It comes up in every review, every time another even happens even away from the unit. It is such a horrible thing no matter how small the incident was. I personally believe it is the wrong approach but it happens more than anyone thinks. I don't think you can ever move on from the event as long as you stay employed there. One coworker who had a patient fall off and subsequently died was practically blamed because she was busy in another room during bedside report with the oncoming nurse and checking drain output on that patient. Management tagged her for missing hourly rounding and not signing the sheet on the door. This coworker went through all these steps and subsequently committed suicide. All was kept hush hush and claimed she was depressed.

Yeah, no kidding! Nursing is the worst when it comes to being unsupporting. Like someone woke up that morning with the intention of hurting someone or making a mistake. Sad!

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Specializes in Oncology.
My place of employment crucifies second victims. One error and you are immediately asked to leave and they will contact you. Then you have to come in several times and talk to charge nurse, assistant manager, manager, director, risk management and whoever else. Then, once allowed to come back to work (usually after a week after), you have to report to a panel of nurses in what people call the room of shame. The panel is comprised of mostly managers of different departments and staff nurses. They basically have you tell your story, what you could have done better, what you will do and then you are basically colored a target on your back. Then, in morning report and unit staff meeting they make you retell your story. They make you put together some kind of poster with 'educational' session and once again the walk of shame in front of the entire unit.

I have never seen any nurse be right after that. They withdraw, have PTSD, issues at home or just grieve forever. Management makes an example out of them forever. It comes up in every review, every time another even happens even away from the unit. It is such a horrible thing no matter how small the incident was. I personally believe it is the wrong approach but it happens more than anyone thinks. I don't think you can ever move on from the event as long as you stay employed there. One coworker who had a patient fall off and subsequently died was practically blamed because she was busy in another room during bedside report with the oncoming nurse and checking drain output on that patient. Management tagged her for missing hourly rounding and not signing the sheet on the door. This coworker went through all these steps and subsequently committed suicide. All was kept hush hush and claimed she was depressed.

Yeah, no kidding! Nursing is the worst when it comes to being unsupporting. Like someone woke up that morning with the intention of hurting someone or making a mistake. Sad!

This is horrid and DOES NOT encourage a culture of safety. This encourages people to hide errors which most likely are systematic. I am so sorry for anyone that has had to endure this process. I would probably quit if it were me.

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Interesting article, as I am off work because of errors I made at work. The emotional stress is unbelievable. I never thought of myself as the 2nd victim in the situation but it is true. There is no EAP with my company. I see that my situation led me to burnout and I was the one that was aware not my supervisor. The company directed me to local mental health support....at least 2months for assessment and another 6 months for counselling. Thanks to my spouse having good benefits I see a psychologist.

I now have figure out where I go from here. I am not sure if I want to go back.

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The 2nd victim is so forgotten most of the time. They are often treated unfairly, as though it could never happen to anyone else. As a nurse manager, I have both hired nurses on probation from the Board and have continued working with nurses who were not terminated, through their supervision. We need to help our nurses, not ostracize them. The pain they feel when their error does harm to someone is incredible. They did not come into this profession to hurt someone. I hope this program spreads.

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Specializes in Psych, Addictions, SOL (Student of Life).

This article is so timely to me. Today I made my 2nd med error for the first time in 15 years. The circumstances don't really matter and the patient was not harmed. But I also had a precept with me on her first day of orientation on the floor. So looking for the positive I choose to make it a learning experience. A "This is what happens when we make a mistake." Moment. I assessed the patient, called the supervisor, doctor and POA. Did the necessary paperwork etc.... The worst moment was when I had to call the POA - I did not say that I made the mistake only that an error had occurred. The person wanted to know if "That stupid nurse would be fired and wanted to talk to the supervisor. So when I got to the supe's office she was on phone with POA stating I'm sorry this occurred, I understand your concerns and assure you that appropriate actions are being taken. After she hung up she turned to me and said "Welcome back to the human race!" We debriefed the incident, looked at root cause and what could be done to avoid future mistakes and that was it.

I do carry a very high mal-practice insurance policy but I don't think I'll need it this time. I picked up afterwards with my precept and we finished our day.

Since the patient wasn't harmed I think the worst part was having it happen in front of a precept. Oh and Hospital gossip is a B%$#h! Within a couple of hours I had several people come by med room and express their concern. Like I am going to go dump 15 years of sobriety over this, though I know several might do just that. I went after work and sat my behind in a meeting though. One more day then I am off for 4 days to attend the APNA conference. If anyone else is going "See you in Phoenix!"

Hppy

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Specializes in Cardicac Neuro Telemetry.
My place of employment crucifies second victims. One error and you are immediately asked to leave and they will contact you. Then you have to come in several times and talk to charge nurse, assistant manager, manager, director, risk management and whoever else. Then, once allowed to come back to work (usually after a week after), you have to report to a panel of nurses in what people call the room of shame. The panel is comprised of mostly managers of different departments and staff nurses. They basically have you tell your story, what you could have done better, what you will do and then you are basically colored a target on your back. Then, in morning report and unit staff meeting they make you retell your story. They make you put together some kind of poster with 'educational' session and once again the walk of shame in front of the entire unit.

I have never seen any nurse be right after that. They withdraw, have PTSD, issues at home or just grieve forever. Management makes an example out of them forever. It comes up in every review, every time another even happens even away from the unit. It is such a horrible thing no matter how small the incident was. I personally believe it is the wrong approach but it happens more than anyone thinks. I don't think you can ever move on from the event as long as you stay employed there. One coworker who had a patient fall off and subsequently died was practically blamed because she was busy in another room during bedside report with the oncoming nurse and checking drain output on that patient. Management tagged her for missing hourly rounding and not signing the sheet on the door. This coworker went through all these steps and subsequently committed suicide. All was kept hush hush and claimed she was depressed.

Yeah, no kidding! Nursing is the worst when it comes to being unsupporting. Like someone woke up that morning with the intention of hurting someone or making a mistake. Sad!

And I bet they will wonder why nurses hide mistakes or med errors. This way of thinking is what prevents staff from coming forward to correct the problem and is of greater detriment to patients. I would not feel safe at all as a patient in a hospital that operated under this mindset.

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I have been a nurse for 10 years. I love nursing and I love patient care. I started my career really early and I feel like minor errors made at 21 were forgiven easier as long as I took responsibility for my actions and learned from them. A decade into my career, I'm noticing a huge shift. I'm not sure if it is with nursing as a whole or with me. Things that used to be nothing more than a conversation went from write ups to terminatable offenses. I've been terminated from my last two travel positions within a month for minor issues (all of which were really big misunderstandings). No one asked me for my account of the events, the accusations contradicted my documentation, and I was not given any notice of the termination. I read the emails sent to my agency where the same nurses giving me positive feedback were accusing me of ignoring my patient's alarms.

I don't know if pay by performance has created a culture of "zero tolerance" for error (or perceived error) in health care, or if there are just too many ambitious nurses who joined the profession to climb the corporate ladder instead of suction trachs. But somehow I began to get bullied more later in my career. I told my agency I couldn't handle it anymore. I can't take care of critical patients if I am more worried about myself than them. So I'm leaving nursing. I know a lot of people who have done the same and it's sad because we are doing it to ourselves.

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