Psychological and Psychosomatic Symptoms of Second Victims of Adverse Events: a Systematic Review and Meta-Analysis.
Journal
Journal of patient safety
ISSN: 1549-8425
Titre abrégé: J Patient Saf
Pays: United States
ID NLM: 101233393
Informations de publication
Date de publication:
06 2020
06 2020
Historique:
pubmed:
29
3
2019
medline:
27
2
2021
entrez:
29
3
2019
Statut:
ppublish
Résumé
Despite growing interest in the second-victim phenomenon and greater awareness of its consequences, there has not been a meta-analysis quantifying the negative impact of adverse events on providers involved in adverse events. This study systematically reviewed the types and prevalence of psychological and psychosomatic symptoms among second victims. We conducted a systematic review of nine electronic databases up to February 2017, without restrictions to publication date or language, examining also additional sources (e.g., gray literature, volumes of journals). Two reviewers performed the search, selection process, quality assessment, data extraction, and synthesis. We resolved disagreements by consensus and/or involving a third reviewer. Quantitative studies on the prevalence of psychological and psychosomatic symptoms of second victims were eligible for inclusion. We used random effects modeling to calculate the overall prevalence rates and the I statistic. Of 7210 records retrieved, 98 potentially relevant studies were identified. Full-text evaluation led to a final selection of 18 studies, based on the reports of 11,649 healthcare providers involved in adverse events. The most prevalent symptoms were troubling memories (81%, 95% confidence interval [CI] = 46-95), anxiety/concern (76%, 95% CI = 33-95), anger toward themselves (75%, 95% CI = 59-86), regret/remorse (72%, 95% CI = 62-81), distress (70%, 95% CI = 60-79), fear of future errors (56%, 95% CI = 34-75), embarrassment (52%, 95% CI = 31-72), guilt (51%, 95% CI = 41-62), and sleeping difficulties (35%, 95% CI = 22-51). Second victims report a high prevalence and wide range of psychological symptoms. More than two-thirds of providers reported troubling memories, anxiety, anger, remorse, and distress. Preventive and therapeutic programs should aim to decrease second victims' emotional distress.
Identifiants
pubmed: 30921046
doi: 10.1097/PTS.0000000000000589
pmc: PMC7386870
pii: 01209203-202006000-00012
doi:
Types de publication
Journal Article
Meta-Analysis
Systematic Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
e61-e74Commentaires et corrections
Type : ErratumIn
Références
Shekelle PG, Morton SC, Keeler EB. Costs and Benefits of Health Information Technology. Evidence Report/Technology Assessment No. 132. AHRQ Publication No.06-E006. Agency for Healthcare Research and Quality: Rockville, MD; 2006.
Ball CG, Sutherland F, Kirkpatrick AW, et al. Dramatic innovations in modern surgical subspecialties. Can J Surg. 2010;53:335–341.
Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009;7:100–103.
Behruzi R, Hatem M, Goulet L, et al. Perception of humanization of birth in a highly specialized hospital: let’s think differently. Health Care Women Int. 2014;35:127–148.
Grisales-Naranjo LV, Arias-Valencia MM. Humanized care; the case of patients subjected to chemotherapy. Invest Educ Enferm. 2013;31:364–376.
Rosenstein AH. Addressing physician stress, burnout, and compassion fatigue: the time has come. Isr J Health Policy Res. 2013;2:32.
Scott SD, Hirschinger LE, Cox KR, et al. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care. 2009;18:325–330.
Wu AW. Medical error: the second victim. The doctor who makes mistakes needs help too. BMJ. 2000;320:726–727.
Reason J. Human error: models and management. BMJ. 2000;320:768.
Canadian Patient Safety Institute. Patient Safety Incident. Available at: http://www.patientsafetyinstitute.ca/en/Topic/Pages/Patient-Safety-Incident.aspx. Accessed October 2, 2018.
Rafter N, Hickey A, Condell S, et al. Adverse events in healthcare: learning from mistakes. QJM. 2015;108:273–277.
Edrees HH, Morlock L, Wu AW. Do hospitals support second victims? Collective insights from patient safety leaders in Maryland. Jt Comm J Qual Patient Saf. 2017;43:471–483.
Van Gerven E, Deweer D, Scott SD, et al. Personal, situational and organizational aspects that influence the impact of patient safety incidents: a qualitative study. Rev Calid Asist. 2016;31(suppl 2):34–46.
Tumelty ME. The second victim: a contested term? J Patient Saf. 2018. doi:10.1097/PTS.0000000000000558. Epub ahead of print.
doi: 10.1097/PTS.0000000000000558
Wu AW, Shapiro J, Harrison R, et al. The impact of adverse events on clinicians: what’s in a name? J Patient Saf. 2017. doi:10.1097/PTS.0000000000000256. Epub ahead of print.
doi: 10.1097/PTS.0000000000000256
Harrison R, Lawton R, Perlo J, et al. Emotion and coping in the aftermath of medical error: a cross-country exploration. J Patient Saf. 2015;11:28–35.
Gazoni FM, Amato PE, Malik ZM, et al. The impact of perioperative catastrophes on anesthesiologists: results of a national survey. Anesth Analg. 2012;114:596–603.
Wahlberg A, Andreen Sachs M, Johannesson K, et al. Post-traumatic stress symptoms in Swedish obstetricians and midwives after severe obstetric events: a cross-sectional retrospective survey. BJOG. 2017;124:1264–1271.
Rodriquez J, Scott SD. When clinicians drop out and start over after adverse events. Jt Comm J Qual Patient Saf. 2018;44:137–145.
Martens J, Van Gerven E, Lannoy K, et al. Serious reportable events within the inpatient mental health care: impact on physicians and nurses. Rev Calid Asist. 2016;31(suppl 2):26–33.
Quillivan RR, Burlison JD, Browne EK, et al. Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses. Jt Comm J Qual Patient Saf. 2016;42:377–386.
Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf. 2012;21:267–270.
Edrees H, Connors C, Paine L, et al. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. BMJ Open. 2016;6:e011708.
Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010;36:233–240.
Medically Induced Trauma Support Services. Clinician support tool kit for healthcare workers 2010. Available at: http://mitss.org/wp-content/uploads/2017/11/Clinician-Support-Tool-Kit-for-Healthcare_05-07-2012.pdf. Accessed October 2, 2018.
Reis CT, Paiva SG, Sousa P. The patient safety culture: a systematic review by characteristics of hospital survey on patient safety culture dimensions. International J Qual Health Care. 2018;30:660–677.
Chan ST, Khong PCB, Wang W. Psychological responses, coping and supporting needs of healthcare professionals as second victims. Int Nurs Rev. 2017;64:242–262.
Seys D, Wu AW, Van Gerven E, et al. Health care professionals as second victims after adverse events: a systematic review. Eval Health Prof. 2013;36:135–162.
Sirriyeh R, Lawton R, Gardner P, et al. Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals’ psychological well-being. Qual Saf Health Care. 2010;19:e43.
Ouzzani M, Hammady H, Fedorowicz Z, et al. Rayyan – a web and mobile app for systematic reviews. Syst Rev. 2016;5:210.
Higgins JPT, Deeks JJ, eds. Chapter 7: Selecting studies and collecting data. In: Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available at: www.handbook.cochrane.org. Accessed October 2, 2018.
Moher D, Liberati A, Tezlaff J, et al. Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. Ann Intern Med. 2009;151:264–269, W64.
The Joanna Briggs Institute. The Joanna Briggs Institute Critical Appraisal tools for use in JBI Systematic Reviews. Checklist for Prevalence Studies. 2017; Available at: http://joannabriggs.org/assets/docs/critical-appraisal-tools/JBI_Critical_Appraisal-Checklist_for_Prevalence_Studies2017.pdf. Accessed October 2, 2018.
Cramer H, Foraita R, Habermann M. Nursing errors and the consequences. Results of a survey of nurses from inpatient care institutions [in German]. Pflege. 2012;25:245–259.
Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007;33:467–476.
Harrison R, Lawton R, Stewart K. Doctors’ experiences of adverse events in secondary care: the professional and personal impact. Clin Med (Lond). 2014;14:585–590.
Cebeci F, Karazeybek E, Sucu G, et al. Nursing students’ medication errors and their opinions on the reasons of errors: a cross-sectional survey. J Pak Med Assoc. 2015;65:457–462.
Deeks JJ, Higgins JPT, Altman DG, eds. Chapter 9: Analysing data and undertaking meta-analyses. In: Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available at: http://www.handbook.cochrane.org. Accessed October 2, 2018.
Chard R. How perioperative nurses define, attribute causes of, and react to intraoperative nursing errors. AORN J. 2010;91:132–145.
Dhillon AK, Russel DL, Stiegler MP. Catastrophic events in the perioperative setting: a survey of U.S. anesthesiologists. Int J Emerg Ment Health. 2015;17:257.
Hobgood C, Hevia A, Tamayo-Sarver JH, et al. The influence of the causes and contexts of medical errors on emergency medicine residents’ responses to their errors: an exploration. Acad Med. 2005;80:758–764.
Joesten L, Cipparrone N, Okuno-Jones S, et al. Assessing the perceived level of institutional support for the second victim after a patient safety event. J Patient Saf. 2015;11:73–78.
Karga M, Kiekkas P, Aretha D, et al. Changes in nursing practice: associations with responses to and coping with errors. J Clin Nurs. 2011;20:3246–3255.
Wu AW, Folkman S, McPhee S, et al. Do house officers learn from their mistakes? JAMA. 1991;265:2089–2094.
Meurier CE, Vincent CA, Parmar DG. Learning from errors in nursing practice. J Adv Nurs. 1997;26:111–119.
Leinweber J, Creedy DK, Rowe H, et al. Responses to birth trauma and prevalence of posttraumatic stress among Australian midwives. Women Birth. 2017;30:40–45.
McLennan SR, Engel-Glatter S, Meyer AH, et al. The impact of medical errors on Swiss anaesthesiologists: a cross-sectional survey. Acta Anaesthesiol Scand. 2015;59:990–998.
O’Beirne M, Sterling P, Palacios-Derflingher L, et al. Emotional impact of patient safety incidents on family physicians and their office staff. J Am Board Fam Med. 2012;25:177–183.
Schrøder K, Jørgensen JS, Lamont RF, et al. Blame and guilt – a mixed methods study of obstetricians’ and midwives’ experiences and existential considerations after involvement in traumatic childbirth. Acta Obstet Gynecol Scand. 2016;95:735–745.
Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251:995–1000.
Taifoori L, Valiee S. Understanding or nurses’ reactions to errors and using this understanding to improve patient safety. ORNAC J. 2015;33:32–42.
Santell JP, Hicks RW, McMeekin J, et al. Medication errors: experience of the United States Pharmacopeia (USP) MEDMARX reporting system. J Clin Pharmacol. 2003;43:760–767.
Hicks RW, Cousins DD, Williams RL. Selected medication-error data from USP’s MEDMARX program for 2002. Am J Health Syst Pharm. 2004;61:993–1000.
Foa E, Riggs D, Dancu C, et al. Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. J Trauma Stress. 1993;6:459–473.
Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA. 1994;272:1749–1756.
Brewin CR. Re-experiencing traumatic events in PTSD: new avenues in research on intrusive memories and flashbacks. Eur J Psychotramatol. 2015;6:27180.
Ehlers A. Understanding and treating unwanted trauma memories in posttraumatic stress disorder. Z Psychol. 2010;218:141–145.
World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Disgnostic Guidelines. Geneva, Switzerland: World Health Organisation; 1992.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
Robinson OJ, Vytal K, Cornwell BR, et al. The impact of anxiety upon cognition: perspectives from human threat of shock studies. Front Hum Neurosci. 2013;7:203.
Laux L, Weber H. Presentation of self in coping with anger and anxiety: an intentional approach. Anxiety Res. 1991;3:4:233–255.
Muscatello MR, Bruno A, Carroccio C, et al. Association between burnout and anger in oncology versus ophthalmology health care professionals. Psychol Rep. 2006;99:641–650.
Cramer P. Anger and the use of defensive mechanism in college students. J Pers. 1991;59:39–55.
Han A, Won J, Kim O, et al. Anger expression types and interpersonal problems in nurses. Asian Nurs Res. 2015;9:146–151.
Booth J, Ireland JL, Mann S, et al. Anger expression and suppression at work: causes, characteristics and predictors. Inter J Conflict Manag. 2017;28:3.
Gurses AP, Kim G, Martinez EA, et al. Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study. BMJ Qual Saf. 2012;21:810–818.
Hollnagel E, Wears RL, Braithwaite J. From Safety-I to Safety-II: A White Paper. The Resilient Health Care Net: Published simultaneously by the University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia; 2015.
NHS Improvement. A Just Culture Guide. National Health Service: London, UK; 2018.
Radhakrishna S. Culture of blame in the National Health Service; consequences and solutions. Br J Anaesth. 2015;115:653–655.
European Health Parliament. Patient Empowerment and Centeredness 2015. Available at: http://www.healthparliament.eu/wp-content/uploads/2017/09/EHP-papers_Patients-empowerment.pdf. Accessed October 2, 2018.
The Joint Commission, Division of Healthcare Improvement. Supporting second victims. Quick Saf. 2018;39:1–3.
Gispin F, Wu AW. Psychological first aid: CPR for mental health crises in health care. J Patient Saf Risk Manag. 2018;23:51–53.
National Patient Safety Foundation’s Lucian Leape Institute. Shining a Light: Safer Health Care Through Transparency. Boston, MA: National Patient Safety Foundation; 2015.
Bethlehem J. Selection bias in web surveys. Int Stat Rev. 2010;78:161–188.
Last JM. A Dictionary of Epidemiology. Oxford, UK: Oxford University Press.
Rinaldi C, Leigheb F, Vanhaecht K, et al. Becoming a “second victim” in health care: pathway of recovery after adverse event. Rev Calid Asist. 2016;31(suppl 2):11–19.