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Invited paper

Navigating uncertainty and complexity: understanding healthcare professionals in addressing patient safety challenges

José Joaquin Mira1,2,3
  • Chair of the ERNST Consortium (European Researchers Network Working on Second Victims) funded by COST Action 19113
  • Head of the ATENEA Research Team, FISABIO, Spain
  • Professor at the Miguel Hernández University, Elche, Spain

ABSTRACT

Providing optimal quality care is a challenge for professionals and healthcare systems around the world. Patients often rely on healthcare providers to assist them with their health concerns and to provide the safest and best possible care. However, despite the best efforts of healthcare providers to deliver high-quality care, unexpected adverse events can affect a patient. These events can be difficult for both patients and healthcare providers to deal with, particularly when they result in severe harm to the patient.

In addition to the physical and psychological toll that these adverse events can take on patients, healthcare providers can also be emotionally affected. Healthcare providers who are involved in adverse events are often referred to as second victims. These professionals are not only directly affected by the adverse events experienced by the patient but also by the response that these events can provoke in other healthcare team members, directives, and within the health institution.

Adverse events often have a systemic cause, meaning they can result from a combination of organizational, cultural, and environmental factors.

Although usually the professional in charge of patient care who is directly related to the harm is singled out as responsible, there is a chain of events and professionals involved in most events. As a result, other healthcare team members may also be involved in the event, either directly or indirectly. This can create a sense of shared responsibility among the team and a shared sense of loss or guilt when adverse events occur.

Healthcare providers and organizations need to recognize the impact of adverse events on patients and providers. By providing support and resources to second victims, healthcare organizations can help mitigate the emotional toll of these events and support providers in continuing to provide high-quality care to their patients. This paper outlines key elements for a better understanding of the second victim phenomenon and just culture principles, in accordance with the ERNST Consortium insights.


INTRODUCTION

Uncertainty and complexity are inherent in clinical practice. While these are not new phenomena, it appears that we are increasingly recognizing and assessing their impact on outcomes differently. We acknowledge that providing care for those entrusted with the responsibility of treating and caring for patients is crucial for achieving positive results.

Uncertainty and complexity contribute to life-threatening events, needle stick injuries, unexpected deaths, violent incidents against healthcare professionals, stagnation in patient progress, complaints, and errors that harm patients. Other contributing factors to errors include fatigue, distractions, equipment and communication gaps, and outdated protocols, all of which can affect outcomes. Additionally, if we fail to discuss errors and break the chain of silence openly, our patients do not benefit.

Studies have revealed that annually approximately 8% to 12% of hospitalized patients [1] and around 2% of those in primary care [2] experience adverse events, with half of these being preventable [3],[4]. Each adverse event relates to one or several healthcare professionals who must confront these stressful situations relying on their personal resources, the support of their colleagues, or institutional resources. This gives rise to the second victim phenomenon, a term coined by Prof. Albert Wu in 2000 [5], which the European Consortium established within the European Researchers’ Network Working on Second Victims (ERNST) has defined as [6] ‘any healthcare worker, directly or indirectly involved in an unanticipated adverse patient event, unintentional healthcare error, or patient injury, and who becomes victimized in the sense that they are also negatively impacted’.

The ERNST Consortium, established in September 2020 and funded by the European Cooperation in Science & Technology as Action 19113, addresses these issues through four working groups. These groups have updated the definition of a second victim, established intervention levels encompassing preventive and restorative aspects, identified key elements of support interventions, compared practices with other highly reliable sectors, and explored resilience models. Furthermore, a new metric has been devised to assess intervention effectiveness; mechanisms have been developed to introduce future healthcare professionals to incident reporting and to addressing their experiences as second victims; and patient safety training content and regulations have been analyzed in Europe, to promote a common response.

The ERNST Consortium holds four International Forums annually and offers between 20 and 30 scholarships each year for Training School. The Training School addresses the second victim phenomenon, discusses innovations in support programs, and shares experiences on program implementation and maintenance. The final international forum, coinciding with the fouryear deadline of the COST Action, will take place in Belgrade (Serbia) on September 2nd and 3rd of this year.

MATERIALS AND METHODS

This paper outlines the main approaches proposed by the ERNST Consortium for addressing the second victim phenomenon. It also covers the principles included in the concept of just culture.

RESULTS WITH DISCUSSION

Professionals experiencing a second victim situation may require support from their immediate work environment, such as emotional first aid [7] provided by trained colleagues or peers, and in severe cases, they may need specialized assistance. Studies have identified emotional consequences such as isolation, shame, fear, flashbacks, anxiety, and insomnia, with symptoms lasting from days to weeks. In some cases, post-traumatic stress disorder may occur. Following a severe adverse event involving a patient, healthcare providers need support to prevent further negative consequences for other patients [8], as their reasoning and clinical approach may alter and they may resort to defensive practices, potentially putting other patients at risk. Therefore, patient safety benefits from healthcare centers designing safety policies that include support programs for second victims and promote the principles of just culture [9].

Second victim support programs, pioneered in the USA, serve as models for the development of new programs. Initiatives like forYOU at the Missouri Hospital [10] and the Resilience in Stressful Events (RISE) program at Johns Hopkins Hospital in Baltimore [11] have demonstrated that peer support is the most effective and acceptable means of organizing this support. Thanks to the efforts of these pioneers in implementing interventions, we now understand the needs of second victims. As we design protocols, pathways, or recommendations to address the consequences of adverse events, it is essential to remember that second victims require the following: to understand the cause of the event, to know who to communicate with and what to say, to avoid feelings of rejection, to obtain emotional support for the day of the event and subsequent days, to feel valued, and to have access to legal advice [12].

In the ERNST Consortium, we have analyzed the various intervention approaches and needs of professionals and organizations, and have concluded that the organization of support programs should consider five stages [7]: (1) prevention at both the individual healthcare professional and organizational levels, (2) self-care of healthcare individuals and teams after a patient safety incident, (3) peer support and triage, (4) structured professional support, and (5) clinical support. In Europe, some of these programs include the Mitigating Impact in Second Victims (MISE) [13], the Buddy Study [14], the Systematic Collegial Help Program (KoHi) [15], and the Procedure for Serious Adverse Events (PSAE) of the Clinico San Cecilio University Hospital [16]. Indeed, there is evidence suggesting that the well-being of providers translates into better outcomes, which ultimately benefit patients.

These programs should not only focus on coping with highly stressful situations or regaining emotional normality after incidents [17]. Second victim support interventions are closely linked to patient safety and must be accompanied by mechanisms for managing the inherent risks in healthcare activities within services, departments, and institutions. Otherwise, professionals are left vulnerable when things go wrong simply because current knowledge and appropriate tools were not applied to organize and execute clinical activities, i.e., the reality of healthcare practice, which is not without risks, was not taken into account.

We have learned that the worst mistake when dealing with errors is to believe that only bad healthcare professionals make mistakes [18]. This idea solely focuses on individual responsibility, and consequently, nothing changes. It merely perpetuates silence and blame failing to bring about any positive change. Ultimately, the patients suffer the most.

In recent years, we have been accumulating information about how organizational factors, leadership styles, the inherent complexity of the task, individual differences in stress response, and other associated factors justify the intensity of the emotional experience of the second victim. Figure 1 illustrates the factors triggering this negative experience.

Figure 1. Factors triggering the second victim phenomenon

Figure 1. Factors triggering the second victim phenomenon

The concept of just culture refers to an organizational environment where managers encourage open discussions about system failures, unintentional errors, and areas for improvement in patient care. It involves avoiding complacency, taking things for granted, fear of speaking up, ignoring fatigue or overload, and acknowledging the uncertainty and complexity of clinical decisions to minimize patient safety incidents. In this context, the priority is to encourage incident reporting, analyze the root causes of incidents, and implement support programs for professionals who have been involved in an honest mistake (Figure 2).

Figure 2. Just culture and the second victim experience

Figure 2. Just culture and the second victim experience

This approach relies on the responsibility of healthcare institution managers to foster an open and honest environment where professionals feel evaluated and treated consistently, constructively, and fairly. Simultaneously, professionals have a duty of care to follow procedures, guidelines, and standards appropriately and to seek ways to create increasingly safer environments.

When discussing just culture, we must differentiate between honest mistakes and those that are not [19]. In 2016, the National Patient Safety Foundation and, in 2018, the National Health Service, in the United Kingdom, proposed a logical, simple, and effective scheme to establish this differentiation [20]. Essentially, after each event, we can assess whether other staff members or teams with similar qualifications and training levels would have acted the same (substitution test) and whether the professional(s) involved were aware of violating predetermined standards (intention test). However, just culture also entails providing guarantees to patients (and by extension to society) that honesty, responsibility, and transparency are upheld both when honest errors occur, and when inappropriate behaviors or certain risks are recklessly assumed.

Misconceptions about human fallibility, the prevalence of blame culture, and the associated attributions of responsibility often hinder the identification of the immediate causes of honest errors. This distorts understanding regarding why errors occur and what actions should be taken concerning those involved, in order to prevent the recurrence of errors. Second victims exemplify this imbalance between understanding the human factor and the social conceptualization of clinical error [21].

Legal certainty regarding professional engagement in patient safety is another crucial issue that requires attention. Typically, two main approaches are employed. Firstly, the person-centered view, where responsibility for a mistake lies with the professional who made it. This approach simplifies the understanding of error causation, attributing the error solely to the individual. However, the consequence is often punitive. Alternatively, the system-focused view acknowledges that a series of contributing factors are at the core of a mistake. This approach seeks fair compensation for the injured party and aims to understand the root causes, in order to prevent reoccurrence. Consequently, the emphasis is not on punishment but on systemic change. Notably, many legal systems around the world have adopted the former approach, necessitating further study to weigh out the pros and cons of each.

Two legal schemes are already being applied [22]. The first is the tort liability system which is widespread around the world. In this case, litigation is required, and two parts contrast their arguments and evidence in front of a judge or jury. The alternative to this is the so-called no-fault system. In this case, medical misadventure can be compensated without the need to prove fault. This is applied in some countries such as New Zealand, Denmark, and Finland.

The blame culture fosters defensive practices and discourages physicians from actively engaging in incident reporting, thus impeding progress in patient safety. Solutions to these challenges are not straightforward, and evidence regarding the best approach to reform is inconclusive, necessitating further research. However, it is evident that addressing the well-being of professionals and promoting speaking up is paramount to enhancing our capacity to avoid adverse events and improve patient outcomes [23]. Additionally, understanding the causes of errors, involving healthcare professionals in safety practices, and fostering a culture where mistakes are acknowledged but are not recurrent are crucial steps on this journey

CONCLUSION

Transitioning from a reactive culture to a safety-generating culture requires implementing and expanding safe practices and risk management within healthcare institutions. This process starts with higher education institutions, which should review the existing gaps in the training of future healthcare professionals on patient care quality and safety. It should be enforced by the top leaders in healthcare facilities, who must promote accountability and empower professionals to feel evaluated and treated consistently, constructively, and fairly, and learn from their mistakes.

Establishing just culture can help in achieving these objectives. Just culture emphasizes not holding professionals responsible for system failures, communication issues, or working conditions beyond their control. At the same time, reckless behavior and negligence are considered unacceptable forms of conduct that must not be tolerated.

The second victim experience, which includes feelings of responsibility for an unintentional error, worrying about a patient with a complicated course of disease, or the feeling of not having done enough for a patient, should be recognized as a workplace problem and not solely a mental health issue. This experience is much more common among healthcare professionals than is commonly believed and it directly and negatively impacts their ability to provide optimal quality care.

It is of the utmost importance that future research delves into the question of whether healthcare organizations with robust safety cultures take concrete steps to provide much-needed support to professionals grappling with the debilitating effects of the second victim experience. Such an analysis would not only aid in identifying and addressing the underlying causes of this pervasive problem but also help in creating a more empathetic and supportive healthcare system for all.

  • Conflict of interest:
    None declared.

Informations

March 2024

Pages 13-20
  • Keywords:
    adverse events, healthcare providers, medical errors, patient safety, just culture
  • Received:
    02 February 2024
  • Revised:
    12 February 2024
  • Accepted:
    13 February 2024
  • Online first:
    25 March 2024
  • DOI:
  • Cite this article:
    Mira JJ. Navigating uncertainty and complexity: Understanding healthcare professionals in addressing patient safety challenges. Serbian Journal of the Medical Chamber. 2024;5(1):13-20. doi: 10.5937/smclk5-49222
Corresponding author

José Joaquin Mira
Miguel Hernández University, Elche, Spain
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


1. Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Murillo J, Ruiz-López P, Limón-Ramírez R, Terol-García E; ENEAS work group. Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events. J Epidemiol Community Health. 2008 Dec;62(12):1022-9. doi: 10.1136/jech.2007.065227. [CROSSREF]

2. Aranaz-Andrés JM, Aibar C, Limón R, Mira JJ, Vitaller J, Agra Y, et al. A study of the prevalence of adverse events in primary healthcare in Spain. Eur J Public Health. 2012 Dec;22(6):921-5. doi: 10.1093/eurpub/ckr168. [CROSSREF]

3. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008 Jun;17(3):216-23. doi: 10.1136/qshc.2007.023622. [CROSSREF]

4. Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 2019 Jul 17;366:l4185. doi: 10.1136/bmj.l4185. [CROSSREF]

5. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-7. doi: 10.1136/bmj.320.7237.726. [CROSSREF]

6. Vanhaecht K, Seys D, Russotto S, Strametz R, Mira J, Sigurgeirsdóttir S, et al.; European Researchers’ Network Working on Second Victims (ERNST). An Evidence and Consensus-Based Definition of Second Victim: A Strategic Topic in Healthcare Quality, Patient Safety, Person-Centeredness and Human Resource Management. Int J Environ Res Public Health. 2022;19(24):16869. doi: 10.3390/ijerph192416869. [CROSSREF]

7. Seys D, Panella M, Russotto S, Strametz R, Joaquín Mira J, Van Wilder A, et al. In search of an international multidimensional action plan for second victim support: a narrative review. BMC Health Serv Res. 2023 Jul 31;23(1):816. doi: 10.1186/s12913-023-09637-8. [CROSSREF]

8. Pellino G, Pellino IM, Pata F. Uncovering the Veils of Maya on defensive medicine, litigation risk and second victims in surgery: care for the carers to protect the patients. Colorectal Dis. 2021;23(2):548-549. doi: 10.1111/codi.15451. [CROSSREF]

9. Tasker A, Jones J, Brake S. How effectively has a Just Culture been adopted? A qualitative study to analyse the attitudes and behaviours of clinicians and managers to clinical incident management within an NHS Hospital Trust and identify enablers and barriers to achieving a Just Culture. BMJ Open Qual. 2023 Jan;12(1):e002049. doi: 10.1136/bmjoq-2022-002049. [CROSSREF]

10. Scott SD, Hirschinger LE, Cox KR, McCoig M, Hahn-Cover K, Epperly KM, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010;36(5):233-40. doi: 10.1016/s1553-7250(10)36038-7. [CROSSREF]

11. Edrees H, Connors C, Paine L, Norvell M, Taylor H, Wu AW. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. BMJ Open. 2016;6(9):e011708. doi: 10.1136/bmjopen-2016-011708. [CROSSREF]

12. Mira JJ, Lorenzo S, Carrillo I, Ferrús L, Silvestre C, Astier P, et al.; RESEARCH GROUP ON SECOND AND THIRD VICTIMS. Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations. Int J Qual Health Care. 2017;29(4):450-460. doi: 10.1093/intqhc/ mzx056. [CROSSREF]

13. Mira JJ, Carrillo I, Guilabert M, Lorenzo S, Pérez-Pérez P, Silvestre C, et al.; Spanish Second Victim Research Team. The Second Victim Phenomenon After a Clinical Error: The Design and Evaluation of a Website to Reduce Caregivers’ Emotional Responses After a Clinical Error. J Med Internet Res. 2017;19(6):e203. doi: 10.2196/jmir.7840. [CROSSREF]

14. Schrøder K, Bovil T, Jørgensen JS, Abrahamsen C. Evaluation of ‘the Buddy Study’, a peer support program for second victims in healthcare: a survey in two Danish hospital departments. BMC Health Serv Res. 2022;22(1):566. doi: 10.1186/s12913-022-07973-9. [CROSSREF]

15. Krommer E, Ablöscher M, Klemm V, Gatterer C, Rösner H, Strametz R, et al. Second Victim Phenomenon in an Austrian Hospital before the Implementation of the Systematic Collegial Help Program KoHi: A Descriptive Study. Int J Environ Res Public Health. 2023;20(3):1913. doi: 10.3390/ijerph20031913. [CROSSREF]

16. Cobos-Vargas A, Pérez-Pérez P, Núñez-Núñez M, Casado-Fernández E, Bueno-Cavanillas A. Second Victim Support at the Core of Severe Adverse Event Investigation. Int J Environ Res Public Health. 2022;19(24):16850. doi: 10.3390/ ijerph192416850. [CROSSREF]

17. Guerra-Paiva S, Lobão MJ, Simões DG, Fernandes J, Donato H, Carrillo I, et al. Key factors for effective implementation of healthcare workers support interventions after patient safety incidents in health organisations: a scoping review. BMJ Open. 2023;13(12):e078118. doi: 10.1136/bmjopen-2023-078118. [CROSSREF]

18. Kennedy D. Analysis of sharp-end, frontline human error: beyond throwing out “bad apples”. J Nurs Care Qual. 2004;19(2):116-22. doi: 10.1097/00001786- 200404000-00008. [CROSSREF]

19. Meadows S, Baker K, Butler J. The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in Patient Safety: From Research to Implementation (Volume 4: Programs, Tools, and Products). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb. Dostupno na: https://www.ncbi.nlm.nih.gov/books/NBK20586/ [HTTP]

20. Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation (Volume 4: Programs, Tools, and Products). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005. [HTTP]

21. Mira JJ. Understanding Honest Mistakes, Second Victims and Just Culture for Patient Safety. J Healthc Qual Res. 2023;38(5):259-261. doi: 10.1016/j. jhqr.2023.08.001. [CROSSREF]

22. Gil-Hernández E, Carrillo I, Tumelty ME, Srulovici E, Vanhaecht K, Wallis KA, et al. How different countries respond to adverse events whilst patients’ rights are protected. Med Sci Law. 2023:258024231182369. doi: 10.1177/00258024231182369. [CROSSREF]

23. Jones A, Blake J, Adams M, Kelly D, Mannion R, Maben J. Interventions promoting employee “speaking-up” within healthcare workplaces: A systematic narrative review of the international literature. Health Policy. 2021;125(3):375-384. doi: 10.1016/j.healthpol.2020.12.016. [CROSSREF]


REFERENCES

1. Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Murillo J, Ruiz-López P, Limón-Ramírez R, Terol-García E; ENEAS work group. Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events. J Epidemiol Community Health. 2008 Dec;62(12):1022-9. doi: 10.1136/jech.2007.065227. [CROSSREF]

2. Aranaz-Andrés JM, Aibar C, Limón R, Mira JJ, Vitaller J, Agra Y, et al. A study of the prevalence of adverse events in primary healthcare in Spain. Eur J Public Health. 2012 Dec;22(6):921-5. doi: 10.1093/eurpub/ckr168. [CROSSREF]

3. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008 Jun;17(3):216-23. doi: 10.1136/qshc.2007.023622. [CROSSREF]

4. Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 2019 Jul 17;366:l4185. doi: 10.1136/bmj.l4185. [CROSSREF]

5. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-7. doi: 10.1136/bmj.320.7237.726. [CROSSREF]

6. Vanhaecht K, Seys D, Russotto S, Strametz R, Mira J, Sigurgeirsdóttir S, et al.; European Researchers’ Network Working on Second Victims (ERNST). An Evidence and Consensus-Based Definition of Second Victim: A Strategic Topic in Healthcare Quality, Patient Safety, Person-Centeredness and Human Resource Management. Int J Environ Res Public Health. 2022;19(24):16869. doi: 10.3390/ijerph192416869. [CROSSREF]

7. Seys D, Panella M, Russotto S, Strametz R, Joaquín Mira J, Van Wilder A, et al. In search of an international multidimensional action plan for second victim support: a narrative review. BMC Health Serv Res. 2023 Jul 31;23(1):816. doi: 10.1186/s12913-023-09637-8. [CROSSREF]

8. Pellino G, Pellino IM, Pata F. Uncovering the Veils of Maya on defensive medicine, litigation risk and second victims in surgery: care for the carers to protect the patients. Colorectal Dis. 2021;23(2):548-549. doi: 10.1111/codi.15451. [CROSSREF]

9. Tasker A, Jones J, Brake S. How effectively has a Just Culture been adopted? A qualitative study to analyse the attitudes and behaviours of clinicians and managers to clinical incident management within an NHS Hospital Trust and identify enablers and barriers to achieving a Just Culture. BMJ Open Qual. 2023 Jan;12(1):e002049. doi: 10.1136/bmjoq-2022-002049. [CROSSREF]

10. Scott SD, Hirschinger LE, Cox KR, McCoig M, Hahn-Cover K, Epperly KM, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010;36(5):233-40. doi: 10.1016/s1553-7250(10)36038-7. [CROSSREF]

11. Edrees H, Connors C, Paine L, Norvell M, Taylor H, Wu AW. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. BMJ Open. 2016;6(9):e011708. doi: 10.1136/bmjopen-2016-011708. [CROSSREF]

12. Mira JJ, Lorenzo S, Carrillo I, Ferrús L, Silvestre C, Astier P, et al.; RESEARCH GROUP ON SECOND AND THIRD VICTIMS. Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations. Int J Qual Health Care. 2017;29(4):450-460. doi: 10.1093/intqhc/ mzx056. [CROSSREF]

13. Mira JJ, Carrillo I, Guilabert M, Lorenzo S, Pérez-Pérez P, Silvestre C, et al.; Spanish Second Victim Research Team. The Second Victim Phenomenon After a Clinical Error: The Design and Evaluation of a Website to Reduce Caregivers’ Emotional Responses After a Clinical Error. J Med Internet Res. 2017;19(6):e203. doi: 10.2196/jmir.7840. [CROSSREF]

14. Schrøder K, Bovil T, Jørgensen JS, Abrahamsen C. Evaluation of ‘the Buddy Study’, a peer support program for second victims in healthcare: a survey in two Danish hospital departments. BMC Health Serv Res. 2022;22(1):566. doi: 10.1186/s12913-022-07973-9. [CROSSREF]

15. Krommer E, Ablöscher M, Klemm V, Gatterer C, Rösner H, Strametz R, et al. Second Victim Phenomenon in an Austrian Hospital before the Implementation of the Systematic Collegial Help Program KoHi: A Descriptive Study. Int J Environ Res Public Health. 2023;20(3):1913. doi: 10.3390/ijerph20031913. [CROSSREF]

16. Cobos-Vargas A, Pérez-Pérez P, Núñez-Núñez M, Casado-Fernández E, Bueno-Cavanillas A. Second Victim Support at the Core of Severe Adverse Event Investigation. Int J Environ Res Public Health. 2022;19(24):16850. doi: 10.3390/ ijerph192416850. [CROSSREF]

17. Guerra-Paiva S, Lobão MJ, Simões DG, Fernandes J, Donato H, Carrillo I, et al. Key factors for effective implementation of healthcare workers support interventions after patient safety incidents in health organisations: a scoping review. BMJ Open. 2023;13(12):e078118. doi: 10.1136/bmjopen-2023-078118. [CROSSREF]

18. Kennedy D. Analysis of sharp-end, frontline human error: beyond throwing out “bad apples”. J Nurs Care Qual. 2004;19(2):116-22. doi: 10.1097/00001786- 200404000-00008. [CROSSREF]

19. Meadows S, Baker K, Butler J. The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in Patient Safety: From Research to Implementation (Volume 4: Programs, Tools, and Products). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb. Dostupno na: https://www.ncbi.nlm.nih.gov/books/NBK20586/ [HTTP]

20. Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation (Volume 4: Programs, Tools, and Products). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005. [HTTP]

21. Mira JJ. Understanding Honest Mistakes, Second Victims and Just Culture for Patient Safety. J Healthc Qual Res. 2023;38(5):259-261. doi: 10.1016/j. jhqr.2023.08.001. [CROSSREF]

22. Gil-Hernández E, Carrillo I, Tumelty ME, Srulovici E, Vanhaecht K, Wallis KA, et al. How different countries respond to adverse events whilst patients’ rights are protected. Med Sci Law. 2023:258024231182369. doi: 10.1177/00258024231182369. [CROSSREF]

23. Jones A, Blake J, Adams M, Kelly D, Mannion R, Maben J. Interventions promoting employee “speaking-up” within healthcare workplaces: A systematic narrative review of the international literature. Health Policy. 2021;125(3):375-384. doi: 10.1016/j.healthpol.2020.12.016. [CROSSREF]

1. Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Murillo J, Ruiz-López P, Limón-Ramírez R, Terol-García E; ENEAS work group. Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events. J Epidemiol Community Health. 2008 Dec;62(12):1022-9. doi: 10.1136/jech.2007.065227. [CROSSREF]

2. Aranaz-Andrés JM, Aibar C, Limón R, Mira JJ, Vitaller J, Agra Y, et al. A study of the prevalence of adverse events in primary healthcare in Spain. Eur J Public Health. 2012 Dec;22(6):921-5. doi: 10.1093/eurpub/ckr168. [CROSSREF]

3. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008 Jun;17(3):216-23. doi: 10.1136/qshc.2007.023622. [CROSSREF]

4. Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 2019 Jul 17;366:l4185. doi: 10.1136/bmj.l4185. [CROSSREF]

5. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-7. doi: 10.1136/bmj.320.7237.726. [CROSSREF]

6. Vanhaecht K, Seys D, Russotto S, Strametz R, Mira J, Sigurgeirsdóttir S, et al.; European Researchers’ Network Working on Second Victims (ERNST). An Evidence and Consensus-Based Definition of Second Victim: A Strategic Topic in Healthcare Quality, Patient Safety, Person-Centeredness and Human Resource Management. Int J Environ Res Public Health. 2022;19(24):16869. doi: 10.3390/ijerph192416869. [CROSSREF]

7. Seys D, Panella M, Russotto S, Strametz R, Joaquín Mira J, Van Wilder A, et al. In search of an international multidimensional action plan for second victim support: a narrative review. BMC Health Serv Res. 2023 Jul 31;23(1):816. doi: 10.1186/s12913-023-09637-8. [CROSSREF]

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