The Second Victim

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GE hosted a fourth safety webcast in an ongoing series, this time focused on "The Second Victim". Moderated by GE's Jeff Terry, the webcast features two guest speakers, Dr. Albert Wu, professor at Johns Hopkins and Jim Conway, adjunct faculty at Harvard School of Public Health who discuss the concept of the second victim. Topics include:
  • What is a successful second victim support program and what are the measures for success?
  • How can leaders create a culture that supports second victims?
  • How should institutions proactively plan to respond to patients, caregivers, media, and board members when an adverse event occurs?


Transcript

Jeff Terry: Hello, and welcome to the GE patient safety organization's continuing series of patient safety webinar. Today's topic is The Second Victim. My name is Jeff Terry. I lead patient safety at GE and will be your moderator.

After this discussion the panelists and I will be live over the telephone to answer your questions. To enter a question you should see a Q&A tab on the lower right side of your screen.

And so we turn to our topic, The Second Victim. When an adverse event occurs our first priority is clearly to address the needs of the patient and family. It is imperative to learn from the mistake and implement improvements. These are complex tasks that require sophisticated systems and structures.

There's also growing recognition that patients are not the only victims when adverse events occur. And there's growing recognition of a need to care for the caregivers involved, aka the second victims, but how to do that well, what kind of support the caregivers need? How can you set up a second victim support program? How should you prepare a 360 degree response plan so that you are prepared to address the needs of patients, family, staff, media, the board, the community, et cetera.

These are the challenges we face. They are complex and they are deeply personal. Joining me today is Dr. Albert Wu, a practicing internist and professor at the Johns Hopkins Bloomberg School of Public Health where he is the Director of the Center for Health Services and Outcomes Research. He was a member of the Institute of Medicine Committee on identifying and preventing medication errors and was senior advisor for patient safety to the World Health Organization in Geneva.

Many of you are familiar with his work, including coined the phrase the second victim in 2000 in an article in the British Medical Journal titled "The Doctor Who Makes the Mistake Needs Help Too." Thank you for being here, Albert.

Dr. Albert Wu: Thank you.

Jeff Terry: I'm also pleased to welcome Jim Conway. Jim is adjunct faculty at the Harvard School of Public Health and Senior Fellow with the IHI. Jim was also Executive Vice President and Chief Operating Officer at Dana Farber Cancer Institute in Boston.

Jim coauthored the popular white paper called "Respectful Management of Serious Clinical Adverse Events," a new version of which will be released in a very few weeks. Jim, thanks for being here.

Jim Conway: Thanks. It's great to be with you both.

Jeff Terry: Let's turn to our question. And Albert I think we'll start with you. As I mentioned in the intro of course you coined the phrase the second victim, and so maybe a two-part question. First, victim is a powerful word. Why did you choose the word victim when describing this phenomenon and, two, can you maybe share a recent vignette to kind of get us all mentally in the right place for the discussion?

Dr. Albert Wu: Well, it's true that the term victim can be a little bit jarring to the ear, but it's intended to acknowledge that when there's a serious adverse event there are almost always two victims, the first of course the patient and family, but the second is the healthcare worker who can really be seriously injured by the same incidents. We do know now that it's really the system that causes a lot of errors and which would contribute to safety.

And there are a lot of hazards in the medical workplace which are caused by how we design our work. And many of them are there and can trip up a healthcare worker no matter how conscientious they are. And they can in a way be victimized by the same incident that also harms a patient.

There's -- there was a recently in the news quite a bit there was a case of a nurse who was a real veteran and acknowledged as being a terrific nurse. She'd been working for 24 years and in perhaps her first serious mistake with consequences she gave a tenfold overdose of calcium chloride to a seriously ill baby. The baby five days later died perhaps as a result of this. It's not really absolutely clear.

The nurse felt terrible. She did all of the right things. She immediately reported the incident to their incident reporting system and admitted her responsibility, stated that she felt awful. She was fired very soon after.

She -- the state began investigating her and six months later she committed suicide. Her mother described that she had just run out of coping resources and continued to be devastated by this incident. There was a survey of nurses in the state shortly after and over half of nurses felt like they would be held personally responsible if they made an honest mistake, which in many ways is as much the system's fault as theirs.

Jeff Terry: That's an extreme example and a tragedy, but one that certainly frames the problem. Thank you. And, Jim, well maybe we'll turn to you. In Albert's response he mentioned that this nurse was fired. In your white paper, "Respectful Management of Serious Adverse Advents, you mention that many providers have figured out you could fire all the staff and it will no safer, so clearly that's not the answer. Could you summarize for folks from your paper what is it that your approach to respectful management says about the second victim?

Jim Conway: Sure, Jeff, it's the -- I think the most important message the white paper seeks to get across is that in the aftermath of great tragedy, the patient, the family, the frontline staff in the organization can all say we were treated with respect. So specifically for the staff member that means that we have designed a system to assure that happens and then we manage to it.

We were very selectful -- selective in the use of the word management because we have to manage to this. We know that management means empathy. The last thing that that staff member intended to that day was to hurt somebody.

It's to support them when they meet a colleague and says how could you have done anything so stupid? We in fact are coming in and being there with them, figuring out together. It's about a very careful assessment. We don't jump to conclusions. How could you have done that stupid thing?

We step back. It's about bringing -- it's about resolution. It's about learning. It's about improvement.

My story was probably from seven or eight years into our journey at the Dana Farber. We had a patient who was having an injection of an anesthetic agent by a fellow, and there was an error in the injection that created very significant neurologic implications for the patient and she was rushed to the Brigham.

She ultimately recovered. We did a root cause analysis and we presented what we learned to the full staff of the Department of Adult Oncology. At the end of the presentation the fellow stood up, turned to the 100 of more colleagues in the audience, looked out and said, "I want to thank you. Throughout this whole process I was only treated with respect." I have to tell you as the leader I sat back in my chair and said, "Amen."

That's progress. We confronted the critical questions we needed to confront, but we never throughout the journey lost sight of that person who comes to work every day in service of the patients and those who care for the patients.

Jeff Terry: And so clearly that's the outcome that, well, you're not going only see, but in those terrible instances we want to manage a second victim. You said in the paper like maybe 20% to 30% of hospitals have a program in place that might lead to the outcome with the fellow that you described. What types of facilities do you find tend to have a program that works? Which types of facilities don't? Kind of where do you, how do you see that curve of maturity of programs?

Jim Conway: Sure. That's a great question. I want to first start out with one a given. And the given is that serious adverse events happen in every organization. The fact that you have one doesn't differentiate you. What you do with it when it occurs does differentiate you.

What we are seeing in the industry is typically the organizations who have developed integrated plans to manage adverse events in the name of the patient, the family and staff and the organization are organizations who have had a very high profile tragedy. They've confronted this tragedy. They have learned from it but, they've also said never again will we be making it up as we go along.

An extraordinary example is Catholic Health Partners, an organization that has developed as a result of a tragedy where the mother of their chief information officer died in their system as a result of preventable harm. They used that tragedy to memorialize a system which they have shared with anybody who wants it around how these events will be managed.

The organizations that we are seeing struggling are the organizations that first have not confronted the realities of practice. They say these things never happen here. The second is when they happen most traditionally the focus is on secrecy, and it's on frankly protecting their legal issues at the expense of everything else. So the first priority and the only priority is to focus on the organization and there is no balanced priority on either the patient, a family or staff.

Jeff Terry: Thank you. And, Albert, so continuing on that theme, if we are in one of these organizations, and hopefully I think many of viewers are those who maybe don't have a program and seek to create one or learn more about this. So with that in mind talk to us about the type of support that you've seen that are given to second victims, how it's organized, what tends to be effective, how programs are set up.

Dr. Albert Wu: Second victims go through two phases that are quite predictable after a serious adverse event. The first is what you'd expect. They feel -- there is shock. They feel terrible. They have recurring thoughts. They may not sleep well. They might be irritable and they are distracted. Some -- that phase lasts for days to maybe weeks.

Some people unfortunately go on to really develop posttraumatic stress disorder and that's something which can last for months, and years and even decades. Healthcare workers need -- healthcare workers who are second victims need two kinds of support. They need emotional support, as we all might, and then they need informational support. They need to understand how this could happen.

The first kind of support can be provided by anyone who is caring and empathetic. The second kind of support is probably best provided by someone who really understands the kind of work they do. A nurse would probably ideally want to talk to a nurse. A surgeon would probably really only want to talk to a surgeon who could understand exactly how this sort of thing can happen and only then could they be reassured.

So a system, a really good system needs to acknowledge that this is the sort of thing that could happen to anyone and happens frequently. It needs to have a policy that says we are behind you. We will always support you and it has to have some procedures which allow that to happen.

It should -- those procedures should pull together the resources in an institution that let the second victim connect relatively easily with counseling resources, with knowledgeable peers, or really with more professional sort of a higher level of help in the few presented cases if they need it. All of this can be done in a very comprehensive fashion, but they can also be done by an organization in a smaller way on a smaller budget.

Jeff Terry: And maybe we can think through that a bit. So the -- for that small or when we think about small hospital or large economic medical center, where does management of the second victim program? Is that in the quality department that you typically see that?

Dr. Albert Wu: I think it often is in quality or quality and safety, but that's often especially in a smaller organization that's also risk management. So I would say either the medical director and this is something about managing care, or perhaps in risk management.

Jeff Terry: And so let's say we are that smaller hospital where risk management is quality. It is patient safety, manages events, is in a whole lot of things happening with a relatively small number of resources. Oh, and I'm sure those in our viewership today if you had to pick one or two elements that they might focus on, given limited resources, limited time, where would you recommend they focus their efforts to get started?

Dr. Albert Wu: Yes. For many organizations that is all the same person. So I think that there are two things that can be done almost immediately and with relatively few resources. And the first is to create a policy. It sounds like a silly thing to do first, but a policy that acknowledges that there are always second victims and that the organization is pledged to support healthcare workers. It's part of their mission. They will always be supportive in handling these incidents.

And the second is to create a way for to create someone to call, to create a number, a phone number, a pager number, someone to call who can provide immediate support and who can connect them with more resources if that's necessary.

Jeff Terry: And to be clear, for that 800 number you mean something different than our 24/7 800 number which is our crisis management team. You mean specific to the second victim, the care to the second victim.

Dr. Albert Wu: It could be the same. It could be to the same crisis management team. It could be to a second victim coordinator, but it could also be one number. It could be a number to an employee assistance program. It could be a number to the medical director.

Jeff Terry: But the important thing is that it's clear to the staff what the number is, how I get help and that the resources are on the other end.

Dr. Albert Wu: I think that raising awareness is more than half of the battle, and so that people know that if something happens they will be supported. And here's someone they can call.

Jeff Terry: Great. Thank you. And, Jim, then, on that note we talked a little bit earlier about ROI for something like this, which of course that's a very common question and discussion with our clients is ROI, right? There's economic pressures. And you were I thought made some excellent comments on that. Could you share your thoughts about the ROI for work like this?

Jim Conway: Sure. I think every healthcare setting around the country today wants to be known as a great place to work. There's extraordinary competition for talented staff. You want the best, the brightest working in your organization and working within great systems.

Well, a great place to work isn't just when it's good, when everything's happy valley. It's also when things aren't going so well, when there is extraordinary challenges. And that's certainly the case right now. You want the feeling that the organization is there to support you.

I've been struck that patient safety actually is an exceptional recruitment and retention strategy. At Dana Farber we had a nursing turnover of under 2%. I asked the nurses why and they told me three reasons.

The first was because of the fact that we were at the cutting edge of oncology, but the second is we had put in place systems to support their safe practice. And the third was because of our partnership with patients and families.

Until they told me that I actually did not appreciate that safety can actually really help us retain staff. And then when there was an opening we had no absence of talent. So that's the first piece is just managing recruitment and retention because we all know is those can be enormous sinkholes of cost if you have tremendous turnover and tremendous challenges filling positions.

But there's two other aspects of this. The second one I think is the most important. We are becoming very clear that outcomes, clinical, financial, service and experience are all linked. The things that are driving our patients crazy are also the things that are driving our staff crazy.

It is exceptionally difficult, if not impossible to achieve extraordinary outcomes if our staff don't feel supported, if our staff don't feel that we are providing an umbrella of safety for them to raise not only the good stuff, but the stuff that is hard. So I see it for that reason.

The third return on investment is Albert talked about there's already we have many of these elements in our organizations. We have employee assistance programs. We have very talented psychiatry and psychology staff.

We have people in our organizations who are very interested in this work and providing the support, but what we haven't done is brought them together in a collective conversation of how together we can get the maximum value. So what I saw was a tremendous return on investment and our EAP dollars, employee assistance program dollars, when we actually made it more part of the work of the organization as opposed to a separate silo doing its own thing and not really talking about it with anything else going on.

Jeff Terry: And so, Albert, another thing we talked about was pretty much the ROI in terms of patient safety. What has been your finding, your learning around care for the second victim correlating to their performance in the future, likelihood to commit errors in the future? What correlation have you found there?

Dr. Albert Wu: It's hard to make a direct link, but it's sort of taking, picking up on what Jim was saying. If you turn around the ROI issue there is burnout is a huge problem in organizations now. And a lot of burnout is not feeling supported, not feeling someone's there, not feeling there's just someone who's got your back. And that can lead to people leaving organizations and people not being as effective as they could be.

It's clear that providing good first aid for second victims I think can provide at least an important first step. It's very clear that second victims in the immediate aftermath of an adverse event are not functioning at their best.

They are distracted. They may be depressed. They may be worried. And by providing support right up front I think you can head off a lot of future problems, both in terms of their giving the best care that they possibly can, but also for the organization in a way and perhaps needing to take care of or replace those people pretty soon.

Jeff Terry: And that makes me think of transparency, which -- and maybe I'll ask this question to you, something I remember reading in your white paper on respectful management. It was the importance of transparency I think most would agree with, but the notion that in many cases when there's a serious adverse event the media's talking about it. The family is talking about it.

People around the hospital are talking about it. It's like everybody's talking about it, but the people in the organization itself because this kind of prevailing mood of silence comes over. So can you comment on transparency and how it intersects with the second victim and what you've seen in terms of around what's the effective for getting that staff member through that period as quickly as possible?

Dr. Albert Wu: Well, I think that what -- this is a tough one because people are cautious about the possibility of litigation and people are trying to do right by the patient and family. I think that it's good that we've gotten to that point, but there isn't necessarily -- there still isn't necessarily a norm to talk about when things go wrong. And I think that what we're aiming for is to change the culture so that people feel more comfortable in discussing the many different kinds of things that go wrong, including the things that go seriously wrong.

One of the ways to do that is to provide opportunities for people to discuss the real stresses, the real stressful events in their lives. Something which was in the media recently was a discussion of Schwartz Rounds, which are a regular meeting for staff to talk about things that are really troubling them. And many of those things wind up being problems with medical errors.

Jeff Terry: Thank you. So and maybe, Jim, one other question I wanted to pick up on was kind of in the ROI maybe, but you talked earlier about the need for this kind of program and this respectful management overall of adverse events to be foundational to the organization's capabilities rather than a new silo that's got to be built or et cetera. So could comment on the foundational role of this kind of work?

Jim Conway: One of the areas that I'm very much a student of is this area of developing high reliability organizations. As I look across the healthcare scene right now there seems to be endless interventions. Everybody has their own intervention. Some days you feel there's 1,000 interventions.

So we're working on medication reconciliation, but we haven't worked on the medication system. We're working on dealing with the second victim, but we haven't talked about what the reliable basis what's the foundational system. One of the things that there is, as we talked about already, there is absolutely no question if you are in the business of healthcare today you are going to have serious adverse events.

Now it's dreaming to think that you can, one, they're not going to happen or you will be able to figure it out as it goes along, much like floods, train wrecks, hospital fires, we need to anticipate and service to our patients and families, staff and communities that these events are going to happen, and establish the system by which we're going to manage them going forward, not only managing to provide support and empathy, but also ultimately to drive the resolution and the learning.

One of the very sobering realities of great tragedy is they can be exceptional nuggets of learning that you can really use as a powerful leverage to drive change and improvement, but unless you have built the foundation to allow you to be an expert at looking for trouble and manage these going forward you're going to miss that opportunity over, and over and over, whether it's a reliable base around the management of adverse events or it's really another very significant foundational area right now is this area of culture, how we understand our organizations, culture, how we manage that culture and how we evolve that.

That's not a separate intervention and you're going to a lot of organizations right now and they're working on culture. Well, culture is again foundational upon which you can build the richness to grow a lot of the other things that we're seeking to do. That's where I see this respectful management of serious adverse events as a foundational process of leadership.

And I want to come back to one of the comments that Albert was making before about who manages these events. At the end of the day it starts with the governing board and executive leadership. There's striking stories in healthcare.

There's one from 15 years ago of Gordy Springer. He was leading the Allina Healthcare System. One of their organizations had a tragic event. He called the organization as CEO of the system and said, "We will work with you through this."

Gordy told me that within 24 hours every hospital in the system had known about his phone call. There's many other stories about this, so it's also understanding that this isn't just the work of them. It's not the work of the director or VP, but it's also the work of governance and executive leadership also as a foundational responsibility going forward.

Jeff Terry: That resonates very deeply with me, so clearly that notion of what are our foundational capabilities and where does this sit? Thank you.

Albert, you started our discussion with the story of the nurse in Seattle, which of course was an extreme example. I wonder if and I know you obviously you work on this great deal, maybe share an example of a well managed incident that comes to mind where you've seen this work with a positive outcome for those involved.

Dr. Albert Wu: Well, at Johns Hopkins we are trying to do exactly what Jim is describing. We're trying to come up with a comprehensive plan for handling safety and adverse events when they happen. And that involves of course taking care the patient and family, but also taking care of healthcare workers and then making sure that we actually learn from the mistakes, we take the information and do something about that.

I think it's this is doing well by doing good because it can really help you maintain your workforce. Awhile ago there was a tragic incident of a fairly young, but very, very sick patient who died in the operating room. And these events are always very traumatic.

The staff was distraught. And I think that we did a few things right. The first thing we did was we had our employee assistance program come in essentially on the same day and talk to the entire OR staff to help them really debrief and download all of their feelings and also to begin to help them understand what happened.

The physician did -- was very smart. He probably almost first went to talk to his mentor, who was a senior surgeon, and so that he could better understand what happened. And I think he got some comfort from that discussion.

He then brought himself straight to our employee assistance program. And even though there's great resistance to ever going to employee, directly to employee assistance he describes this as being really helpful. And he told me that while he still thinks about this problem almost every day it's he can go on. He's back doing all the terrific things that he is there to do. And I think the institution has really benefited from this experience.

Jeff Terry: Thank you. And you mentioned those early conversations with the employee assistance program. And in both of your work I've read about different phrases that we should use. And I'd love to share some of those phrases with our audience, phrases that as opposed to asking who's to blame here, saying hey let's see if we can all sort this out. So I'd love to hear from each of you examples of this language that is the right kind of language around things like speaking to the second victim, Jim, if you want to?

Jim Conway: Sure. Well, one of I guess my expressions became a mantra in my learning at Dana Farber. And it's this notion that our systems are too complex to expect merely extraordinary people to perform perfectly 100 percent of the time that we as leaders have a responsibility to put in place systems that support safe practice.

So it's the clarity of that message around so when one of these events happened people understand that leadership understands its exquisite role in these events. And the second was we often talked about the burden, the responsibility and the power that when these tragedies happen we carried the burden for them, and we should. We have failed our patients and families.

We also had the responsibility to learn everything we could. What we tripped over is something we've already talked about is the power that these great tragedies can have to make care better, but I am struck with when I go into any organization that has had one of these very serious events is the nuns would describe it as I had their undivided attention. There was the most unbelievable commitment to learn everything they possibly could right so that nothing like this could happen again.

The third one and very specific to the point that you talked about is when something happens if the first question you ask is who did it you're dead in the water. If the first question that you ask is what happened then that takes you into a very different place.

One of the areas we've talked about in this is staff involvement after an adverse event. If in the investigations of adverse events staff isn't included people say that the focus is on understanding what, who did it, but if staff is included in the RCA and the investigation, then staff report over and over then the focus is on what happened.

Jeff Terry: (inaudible)

Dr. Albert Wu: Well, when these things happen I can speak personally the thing you want to do is hide your head in the sand, isolate yourself and hope and wish it will all go away. And I think that there are things that can be said. I think that it's possible to -- I think it's possible for an organization to increase its capacity to be empathetic and to say things that are actually helpful.

A few things that you can say first are, since people tend to ignore and walk around, step around people who've been involved in bad mistakes. And the first thing you can say is how are you doing. And often the person will be very grateful because people have been avoiding them.

The second thing you can say is this must be really difficult for you. Let me tell you about something that happened to me. And we all have a story or many stories of things that we could share and it really does make the person seem, feel less like it's just them, no one's ever done this before. This is horrible.

The third thing is to reassure them that you're still a good, and competent and valued nurse or physician. Jim's talking at least indirectly about the investigation, which sometimes feels more like an interrogation or inquisition. People feel really persecuted when they, when people are talking to them. And I think the first thing that we could say at the outset of every investigation is not even not what did you do, or maybe not even what happened, although I like that too, but how are you doing, because if that person knows enough for you to talk to them they're probably feeling pretty bad.

Jeff Terry: That's a great point. So even and just listening to you share that how are you doing I feel my own kind of stress level. It's a very humanizing question and it strikes me that that would be very effective. Thank you.

So I think we'll wrap then and, Dr. Wu and Jim, thank you very much for joining us and sharing your thoughts. And on behalf of Performance Solutions at GE I want to thank our audience for joining us. Our hope is to provide a provocative dialogue and we'll continue to do so. With that we'll transition to the live question-and-answer, and again you should see the ability to enter questions in the bottom right hand side of your screen.



QUESTION AND ANSWER SESSION

Jeff Terry: All right. And with that we live over the phone. This is Jeff Terry from GE. I'm joined by the two gentlemen that you just watched. That's Jim Conway and Dr. Wu. And I'm pleased to say that we've got, well, a little over 200 people on the line and we've got I think several dozen questions. So thanks for your participation and why don't we jump in to see if we can address as many of these as we can.

The first question that I'll address is very straightforward. It comes from someone in New York. And the question was where can we find a basic sample policy? I'm sure many have that question. And there's a website I'll draw your attention to and that's misstools.org. I'll spell that. It's M-I-T-S-S-Tools.org, M-I-T-S-S-Tools.org. MITSS is an organization and they've pulled together a tool kit that you can find at that site under the tools for clinicians. That includes sample policies and things that are available free of charge to get you up and running.

Dr. Albert Wu: Yes, Jeff. MITSS is an interesting organization. The founder is actually a patient who was injured by healthcare and she partnered with that physician to try to take care of both first and second victims. So they're a unique organization that are doing a lot of good work. Both Jim and I are sort of helping them out a little bit.

Jeff Terry: Sir, thank you. Very good, and then I guess there are wonderful questions coming in, so let's keep going. The second question and maybe I'll ask this of you, Albert. There's a couple around this legal vein which are around the legal implications of a second victim dialogue between colleagues, your comments on the legal implications and specifically the protection of that information if the hospital is part of a PSO.

Dr. Albert Wu: Well, I think this is a common question. People on the one hand are being encouraged to talk more to be more open about patient safety and medical errors. And this sort of fits right in.

An ideal program provides support for second victims and of course their conversations between the second victim and whoever is providing that emotional first aid. The question is is that person then subject to being subpoenaed? Are those conversations protected?

There is some variability from state to state. And in many states, including Maryland, if the second victim program or the second victim activity is part of a medical staff committee, so for example our second victim program is part of patient safety, then all of our activity including working with second victims, counseling people is protected.

Now this is not true in every state and for that reason there is also protection which is at a higher level, at a federal level which is offered by patient safety organizations. So if an institution is part of a PSO they can also get protection by virtue of that membership.

Jeff Terry: And of course there's a whole -- there's a depth of things there in terms of joining the PSO, management of a patient safety evaluation system and patient safety work product which maybe if the questioner is curious we can address offline, but with those systems in place then that information should be able to be tagged as patient safety work product and protected under the protection of the patient safety organization.

Thank you. So with that I'll ask a question to Jim. And I've got a few questions, two from Pennsylvania in a similar vein which is around protecting the nursing staff. And this questioner says that the local healthcare system sometimes uses nurses as scapegoats, blaming them when lawsuits occur and that there's not a lot of motivation to change that behavior.

So clearly that's a complex question but, Jim, in your view what have you seen that's been done? What can be done to motivate change in terms of actually being more thoughtful in taking care of staff after these incidents?

Jim Conway: Thanks, Jeff. First, as a leader this is a question I've lived quite intently as the chief operating officer of the Dana Farber Cancer Institute after the tragic death that killed Betsy Lehman, the wife of one of our employees and the Boston Globe health reporter. We went through all of the shame, and change and challenges associated with that. And we -- and it was not only external. It was also internal. It was clinicians holding themselves personally accountable for the outcomes.

And what we realized as an organization and the accreditors realized is we could have fired all of the staff and done nothing to improve safety or the reducing the chances of that happening again. I think what is I am so struck with in clinician practice is how clinicians have adopted and embraced the notion of first do no harm, but I think we have taken it to an extreme and we have -- we deliver healthcare based on the premise that extraordinary people are going to be perfect 100 percent of the time.

And that will no matter how good you are you suffer from being human and you have to make mistakes. So what we're seeing across the country, and I spoke in the mantra that I gave during the video part is that we have to put in place systems to support safe practice.

Specifically relating to nursing I am unbelievably excited. I just had the opportunity to speak at the Society of Pediatric Nursing meeting where an extraordinary focus is being put on patient safety and patient effort and just culture in patient safety. [Linda Cronin Waite] is leading the (inaudible) discussions within nursing, 500 clinical and academic leaders focused on this with tremendous excitement over the possibilities.

And just on Monday of this week I met with all of the nurse execs of the Kaiser system and their academic leaders to look at how they step back and look at the academic and the clinical sphere of nursing and the way that we're putting in place in systems that are not -- that are focused on the patient and family, but also supporting the nurse through safe practice. And the final thing that's made this very front and center over the last few weeks, and the last week in particular, is during this nursing strike in California a child -- a patient died of what is reported to have been preventable harm.

And what I'm struck with is the discussion is focused on the nurse, nurse, nurse. And there's a real question about whether or not the system that was supporting that nurse was a good system. Or was it just a matter of time whether or not it was a permanent staff member or a temporary staff member that they were going to be tripping over this process, so a lot of promise, but we have to become increasingly focused on asking the question what happened and not the question who did it.

Jeff Terry: Thank you for that. And if I got -- I certainly think the trend is towards more thoughtful and more enlightened management of the second victim programs. If I work in a hospital where perhaps we're late to that enlightenment, any one piece of advice, any one thing that you might recommend, a technique that I might try to get the attention of administration and perhaps spark change at a local level?

Jim Conway: Yes. I think creating the opportunity to be humbled you will see in the MITSS resources and the [I try] white paper that there's extraordinary work being done at organizations around the country. I have been very impressed that many organizations if you show leaders information of work that's being done on in another organization, and that's an organization they respect that will -- that opportunity to be humbled can be a huge leap to get to the next place.

Jeff Terry: Thank you. And to the resource comment there are several questions online, so I'll get -- I'll state the website where there's a tool set with some actual policies and things of starting points. And that's the MITSS tool set at mitsstools.org. And I'd also draw your attention to the IHI website where you can find Jim's white paper.

And if you're looking for Jim white paper specifically, which is "The Respectful Management of Serious Clinical Adverse Events," that is available of course at IHI, but also if you go to that the website that brought you to today's webinar you -- it's linked directly from there. That's the next level about GEhealthcare.com/safetywebcast. At that website you can also direct link to Jim's white paper.

So, Albert, with that I'll ask the next question of you. This one's from a hospital in Chicago. And the question is what type of training does your second victim support team go through? Is there a curriculum that you recommend?

Dr. Albert Wu: So we have a -- I think it's a very good question and I think that any organization that's considering this or setting this up should be thinking about this. We are actually in the process of developing our curriculum. It's a little bit of a work in process, a work in progress.

And it will involve approximately a day of training which includes some basics of patient safety and system causation of medical errors and patient harm. The concept of the second victim and some idea of just how common a problem it is, including the fact that perhaps half of healthcare workers who are surveyed will report having experienced being a second victim sometime in their career, and then some skill, some basic first aid skills, including things to say and things not to say, and finally pointing out some resources that are available.

I think very few organizations can develop the [novo] an entire support program and the around the second victim. And the only reasonable solution is to make do with initially with many of the resources that already exist, including hospital chaplain services, employee systems programs and so forth, but we are administering this training to people who volunteered for a peer support program. And these were our people who are going to get a little more education, who are going to be actually taking this course.

Jeff Terry: And along the lines of that there's a similar question. This one is from Philadelphia. And it's the question, Albert, is your -- what have you learned about the effectiveness of a peer response versus an EAP intervention? Does one tend to be more effective or more suited for different situations?

Dr. Albert Wu: So it's a great question and I don't really know the answer to it. At the present time employee assistance programs are widely and greatly underused. When I spoke to the employee assistance program -- did I say peer assistance? I'd say rather the employee assistance programs that almost institutions have are really radically underused.

When I spoke to our employee assistance counselors, there are a least a dozen of them, I asked each of them how many second victim type problems they've dealt with in the past year. And each of them mentioned one, two or three.

We know these things are happening all the time, and so obviously people are not utilizing this resource, people who are really professionally trained to provide comfort, and support and longer term counseling if need be. So that's a resource which is -- which could be effective. And when people use it they generally report that it's very effective, though it's a little scary for people to refer themselves to employee assistance. People often are sent to employee assistance and that's the only reason they go.

The peer support programs I think have not been fully tested yet. The program that is run by Sue Scott at University of Missouri includes about 50 peer supporters, peer counselors who are volunteers. And they have had -- I think they've had great success with their program, but they haven't compared it to an EAP-based program.

Jeff Terry: Well, perhaps over time I'd like to be part of the conversation that kind of source that out, which is effective in different situations. And maybe to build on that, Jim, I'll ask a question and is kind of in that same vein, with this question is from Houston. And the question is what would you say to an institution that's afraid to let EAP get involved at the outset because of fear that it will interfere with the root cause analysis?

Jim Conway: Whoa. So the whole goal of the root cause analysis is to find out what happened, why it happened and what's being done to prevent it from that happening again. A byproduct of the RCA is also a byproduct of healing.

As people sit around the table, and I can tell you this from multiple RCAs, it's a very difficult, it's a very challenging and it's a very human -- the devastation of the people sitting around the table as you go through what happened is quite exceptional. No matter who's sitting around the table that process alone won't help you get through a good process of discovery and learning.

So I think that the EAP, or other psychology, or psychiatric resources or professional resources are also going to be crucial. I just think of some of the experiences I've had going to a table are just -- I was working with an organization recently around a medication error that killed a child. And as we're talking about it the director of pharmacy broke down.

And after the meeting I said to the CEO, what support is the director of pharmacy getting? And she wasn't getting any. So I think it's part of a collected whole to answer the three questions, what, why and how can we prevent this from happening again.

And I think it will also support the overall healing, as Albert had talked about consistently, is that these stories, this devastation goes on for years for clinicians. And it's a multipronged approach to get them to that point so that they can successfully participate in collaborated care moving forward.

Dr. Albert Wu: To take off on what Jim was just explaining an insensitive root cause analysis investigation can really exacerbate the situation for a second victim who should be intact and in good shape to help with what finding out what happened, but if they experience it as an inquisition it just seems to me that they're going to be a lot less effective at providing sort of objective, un-defensive explanations of what did happen.

Just going back for a second to which resources might be most effective in which situations. I don't think it should be either or peer support or employee assistance. There is some evidence that there's a real pyramid of how people are impacted by an adverse event and at the base of the pyramid there are many people who are effected for awhile, perhaps not as severely or as deeply. And they can be supported and perfectly adequately by their colleagues as long as their colleagues are in fact helpful and supportive.

There are a few percent of people who need more support, who need more help, perhaps with a more severe incident or if they're themselves just more sensitive people. And a trained peer supporter who can provide more than just a general colleague on a unit can be more helpful there.

And then there's just a few percent of people who really need more professional, more longitudinal support. And those are people who certainly should go to EAP, but after that they should probably be referred on to ongoing professional help. So I think that you want to have both or all three of these levels of support, not just one.

Jeff Terry: Very good. Thank you. And with that I think we'll wrap. I should say based on the number of questions which continue to come in we're clearly we picked an important topic and the right topic. And the thrust of the questions that remain tend to be twofold. One is looking for additional resources, and as I mentioned, Jim's paper which is excellent and quite thorough is available on the respectful management events. That's from the IHI. And then that MITSS toolkit has several things available for starting points of policies and things that you could build from.

And the second vein of questions that remain just underscores the challenges, which are along the lines of our questioner from Pennsylvania, which is how do we change the culture from one of blame? What do we do to get when these punitive situations, how do we avoid or change the culture from looking for scapegoats? And I think those just underscore the amount of work that we have to do to raise awareness, raise education and get these programs built.

And my hope is that this discussion and event was a part of the good in making that happen. So I want to thank very much Jim Conway and Albert Wu for participating --

Jim Conway: Thank you.

Jeff Terry: -- and all the folks at GE who made this happen.

Dr. Albert Wu: A real pleasure.

Jeff Terry: And we look forward to working with folks again in the future. Thank you very much for joining today.

Dr. Albert Wu: Thank you, Jeff, and thank you, everyone.

Jim Conway: Thanks. Bye-bye.

Comments (2)








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  • Chad Tharan September 28, 2011 4:09 PM

    great webcast

  • marcus amano September 30, 2011 6:14 PM

    great program with respected speakers. Appreciate the quick turn around posting the recorded program to clarify items missed.


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