Problem Addressed

• Uncertain, but likely substantial, number of second victims: Although the overall magnitude of the problem has not yet been quantified, a growing body of literature suggests that many providers become second victims at some point in their careers. A survey of 898 employees of University of Missouri Health Care found that about one-third had experienced emotional responses—such as depression, anxiety, and concerns about job performance—within the past year as a result of an unanticipated adverse event; 15 percent contemplated leaving the profession.²
• Negative impact on patient care and safety: Second victims commonly report postevent responses such as extreme fatigue, sleep disturbances, poor concentration, frustration, anger, excessive excitability, and avoidance of the patient care area involved. These responses can have a negative impact on the provider’s ability to provide quality care and ensure patient safety, potentially creating a “reciprocal cycle” of subsequent suboptimal care and medical errors.^3,4
• Failure to provide emotional support: Second victims often require immediate emotional support following an event, but most organizations have no formal programs to provide such assistance.⁴ Two-thirds of respondents to the University of Missouri Health Care survey reported that they worked out their depression and anxiety on their own; 83 percent would have preferred to receive support from the institution rather than being forced to seek out external sources.²

Description of the Innovative Activity

• Education about second victims: The hospital has raised awareness of the second victim phenomenon and available hospital resources via posters displayed throughout the facility, brochures placed in staff lounges, computer screen savers, magnets, and presentations at staff meetings. All communications encourage employees to seek help if they feel they have become a second victim.
• Three-tiered emotional support structure: The hospital offers a formal support structure based on an internally developed model known as the Scott Three-Tiered Interventional Model of Second Victim Support. Second victims can access three different levels of support, as outlined below (second victims can request initial support at any tier, or they may be referred to subsequent tiers):
  
  • Tier 1: Immediate emotional “first aid”: Frontline managers and supervisors on individual units proactively offer care and compassion to second victims within their own departments. Whenever they hear about an event that might create second victims, they immediately approach the involved caregivers to ask, “How are you doing?” They allow the caregivers to share their stories and then communicate positive messages to them, emphasizing that they remain trusted and respected members of the unit. They also conduct a postevent professional critique of the case so that the second victim can participate if so desired. The managers and supervisors will refer second victims to Tier 2 interventions if requested (see below), although approximately 60 percent find that Tier 1 support proves to be sufficient to meet their needs.
  • Tier 2: Support from trained peer supporters and other internal resources: Tier 2 features nearly 100 trained peer supporters, known as the “forYOU” team, who provide additional emotional support. The team consists of physicians, nurses, medical students/residents/fellows, rapid response team members, social workers, respiratory therapists, and other allied health care workers embedded on various shifts in high-risk clinical areas, such as operating rooms, intensive care units (ICUs), pediatrics, emergency department (ED), and the code blue team. Team members remain on call for all health system facilities 24 hours a day, 7 days a week to enable rapid response to second victims. Approximately 30 percent of second victims require Tier 2 support. Services offered by the team include the following:
    • Indepth counseling: The forYOU team provides more indepth and formal support than the frontline supervisors can, setting aside two or three scheduled blocks of time to listen to and discuss the second victim’s needs. The forYOU team members may or may not have a professional relationship with the second victims they assist.
    • Mentoring of frontline managers: The forYOU team members serve as mentors to frontline managers who would like advice and support when working with second victims directly.
    • Referrals to other resources and to Tier 3: The forYOU team may refer second victims to other internal resources provided as part of Tier 2, such as patient safety experts and risk management personnel, who can provide long-term support during an institutional investigation or legal action. They can also refer second victims to a member of the Tier 3 referral network (described below).
  • Tier 3: Referral for counseling: During the first 10 months of the program, 13 of 49 individuals (roughly 25 percent) receiving Tier 2 services were referred to a third level of support designed to provide access to additional professional counseling and guidance to second victims who require a level of support that exceeds the expertise of the forYOU team. The referral network includes chaplains, employee assistance program personnel, social workers, and clinical psychologists.
• Monthly meetings to share best practices: The forYOU team meets monthly to discuss cases and share success stories and best practices in responding to and communicating with second victims. Details that could lead to the identification of patients or second victims are not shared during the meetings. Referral network members attend these meetings to provide mentoring and education to the team.

References/Related Articles

Contact the Innovator

Innovator Disclosures

Results

• “I don’t think I’ve met a doctor over the age of 30 who hasn’t experienced at least two memorable adverse patient events. By the time folks get to my point in their careers, they will probably have experienced at least four to six such events. Even many years after these events occurred, I find myself thinking about them several times a year, rehearsing once again if there was anything else I could have done to avoid the negative outcome.”— a physician with more than 25 years of clinical experience
• “To have someone call me out of the blue just to offer support was a wonderful thing. It was like a burden was lifted off me, knowing I didn’t have to get through it alone.” — a physician, after activation of the forYOU team
• "Thank you for the call on Thursday. It meant a lot to me to feel like someone cared enough to call and see how I was handling things. I most certainly needed to get myself back together. Thank you." — A nurse, via e-mail, to a peer supporter after activation of the forYOU team
• “There was a forYOU team member present at a recent Code Blue, and she helped a staff member who I was extremely worried about. She seemed to know just what to do!” — A nurse

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Forming interdisciplinary team: With the support of health system leaders, the Office of Clinical Effectiveness created an interdisciplinary team to design the program. Team members included physicians, nurses, clergy, social workers, and representatives from the Employee Assistance Program and the patient safety, risk management, and education departments.
• Conducting literature review: The team conducted a literature review but did not uncover any specific strategies for helping second victims. The team did identify some related initiatives and programs, such as the Medically Induced Trauma Support Services (MITSS) Program and the Critical Incident Stress Incident model, which support professionals who respond to traumatic community events.
• Surveying staff: The team developed and distributed a 10-item, Web-based survey² to health system staff; the survey solicited information to determine the frequency and nature of the second victim phenomenon within the organization.
• Interviewing second victims: The team interviewed 31 second victims within the health system to understand their experience and gain information to inform program development.³
• Developing three-tiered system: Based on the interviews and the survey results, the team developed the Scott Three-Tiered Interventional Model of Second Victim Support. The team also created and distributed printed materials describing the program, and made presentations to different groups of staff, with the goal of increasing institutional awareness of the second victim phenomenon.
• Training: Both frontline managers and forYOU team members received training on how to communicate and work with second victims, including scripted language to guide conversations. Additional details on the training are provided below:
  • Frontline managers: Frontline managers received brief (60-minute) training on the definition of a second victim, research on the second victim phenomenon, internal research findings on second victims and their needs, clinical situations that might evoke a second victim response (such as incidents involving pediatric patients, a medical error, or an unexpected patient death), communication skills, and referral procedures.
  • forYOU team members: forYOU team members attended 8 hours of training that covered the above topics in greater depth. Sessions included didactic education, small-group work, and simulated response to events.

Resources Used and Skills Needed

• Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
• Costs: Program development costs were modest, consisting primarily of the need to provide unit coverage while staff attended upfront training, and the creation of marketing materials such as posters and brochures (which cost approximately $4,000). Ongoing operating costs for the program are negligible.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Increase awareness of second victim phenomenon: Produce posters and brochures that explain the phenomenon. In addition, encourage department managers to discuss it during staff meetings, and/or create a “journal club” in which participants can read and discuss published articles on the topic.
• Ensure strong administrative framework: One individual should be given responsibility for coordinating, overseeing, and monitoring the program. When multiple sites are involved in an adverse event, a team leader should be assigned at each facility to coordinate activities and mentor team members.
• Select participants with passion for the topic: Members of the Tier 2 team should be selected based on their engagement and understanding of the second victim phenomenon, and be driven by a true desire to help their peers. Often, team members have been second victims themselves and hence can empathize and share stories with others.
• Focus on areas likely to produce second victims: The program should focus on units, departments, and teams likely to produce second victims, including (but not limited to) the ICU, ED, rapid response team, and pediatrics.
• Leverage existing resources: Many individuals in the organization likely have the skill set necessary to help implement a second victim response program. For example, social workers are trained listeners, and ED staff are generally familiar with techniques for managing stress after critical incidents. Risk managers and patient safety officers can also provide valuable support to second victims.

Sustaining This Innovation

• Build on successes: Department managers and team members typically find helping colleagues to be a very meaningful and moving experience. Once they help one colleague, they feel more confident in helping subsequent second victims.
• Secure commitment from staff before training: Given the natural turnover that occurs in any organization, ask Tier 2 team members for a 1-year commitment to the program before investing in training them.