Last year, I wrote an article which discussed the second victim phenomenon. The prevalence of second victims is likely to be high, given that up to one in every five hospital admissions is associated with an adverse event.
Every day, many healthcare professionals throughout the world become second victims of adverse events, the latter being primarily due to defective systems and not incompetent or reckless individuals.
The reason why we don’t hear about them more often is because of the shame and helplessness that comes with being a second victim, as well as the fear of reprisals.
Current best practice dictates that (among other things) all serious adverse events are reported, investigated thoroughly, and any shortcomings in the process/system be remedied. Any learning that occurs from the investigation and/or attempts to reduce the risk of patient harm should be disseminated.
A non-punitive approach is encouraged to improve the rate of reporting of errors and to promote a patient safety culture. However, in many cases, there lies a noticeable gap between theory (manifest in policies and procedures, white papers, speeches, etc.) and practice.
At Teh & Associates, we focus on what was done (or not done) immediately after a serious event, as opposed to ploughing through reams of policies and procedures, in evaluating an organization’s capacity to respond when things go wrong. Over the years, this has proven to be a much superior method of assessment because it examines the quality of the organization’s processes in dealing with adverse events when they actually occur, i.e. where the rubber hits the road. True colors start to show when the sh*t hits the fan.
Of course, we have met some CEOs that have “perfect” organizations, i.e. ones in which “bad things never happen here.” When we encounter such individuals, we get an instant picture of their organization’s patient safety culture (and the enormous amount of work that lies ahead!).
A few days ago, the story of Kimberly Hiatt, RN, broke out in the popular press. In this unfortunate case, Hiatt, a nurse at Seattle Children’s Hospital, administered calcium chloride to a critically ill baby that was ten times higher than the prescribed dose (1.4 grams vs 140 milligrams). This act might or might not have contributed to the demise of the child, who died five days later. Hiatt filed a report of her medication error in the hospital’s electronic reporting system on the same day of the error. This was the only serious error that she was known to have made in her 24-year career at the same hospital.
After her mistake, Hiatt was escorted from the hospital and was “immediately put on administrative leave and then fired within weeks.” A few months later, Hiatt hanged herself in her family’s home, apparently from depression and sense of hopelessness. There were other factors that contributed to Hiatt’s dismissal (you can read about them in this article) – read objectively, the overall picture is not consistent with the “just culture” that the hospital claims to espouse.