Adverse events may affect the personal life, family and work of healthcare professionals involved. Healthcare professionals are considered as the 鈥榮econd victim鈥� in the circumstance of adverse events. Adverse events also negatively impact and damage the reputation of affected health organisations 鈥� considered as third victims by undermining people鈥檚 trust in these institutions and in the delivery of healthcare. There is increasing literature addressing the organisational impacts after adverse events as the third victim phenomenon.
Preventive and supportive interventions to prevent and minimise the impact of adverse events will be considered at and across the different levels of the health system:
at the macro level (legislative, regulatory, professional associations, trade unions, occupational health and safety),
at the meso level (at the level of healthcare service providers)
at the micro level (at the level of patient care involving frontline healthcare professionals, carers and patients)
This study unit is intended to give the knowledge and skill to health care professionals and managers working at the different levels of health and social care to empower them to prevent adverse events and emergencies and to be knowledgeable and skilled on how to deal with them when they happen.
This study unit is also intended to give knowledge to professionals who support healthcare workers after an adverse event including Human Resources and Occupational Health and Safety Managers, Psychologists, Lawyers.
This study unit is aimed to incorporate different aspects relevant to the preventing and dealing with adverse events including corrective and preventive actions, building resources and infrastructure required such as employee support programmes, psychological safety and support, occupational health and safety, legal framework, governance structures. The unit will consider all the levels of the healthcare ecosystem and the need for an integrated approach.
This study unit should cover knowledge as well as emphasise the skills and behavioural aspects needed in practice.
Topics to consider include the following:
Skills supporting the safety culture in healthcare
communication, CANDOR
leadership
teamwork across professions and with management
interprofessional training,
speaking up about mistakes
impact of safety culture on practice, avoiding defensive practice
healthcare worker stigma, fear and shame to speak up, invincible attitude, failure culture, learning from experience
emotional impact of errors, managing emotions
caring for self, coping behaviours,
occupational disease / sensitivity to mental health issues
dealing with aggressive and abusive/disrespectful behaviours The 鈥榲ictims phenomena鈥�
the first, second and third victims phenomena
the victims phenomena in association / as an extension of patient safety, professional safety and organisational safety
second victims as an occupational disease
perspectives of the 鈥榲ictims鈥� phenomenon by different stakeholders
Eurobarometer, measurement of citizens perceptions
Safety culture
patient safety culture, the patient safety experience
theoretical framework and factors constituting patient safety culture
tools for measurement and monitoring of patient safety culture and safety experience
safety culture within healthcare organisations
learning from mistakes and near misses
safety culture across the healthcare ecosystem
healthcare professional safety and psychological safety
just culture, blame free-culture, safe culture
Governance across the healthcare ecosystem
adverse events reporting and learning from adverse events
factors affecting adverse events reporting
quality management, continuous improvement at the organisational level; monitoring and evaluation
the learning organisation
organisational culture, public and private organisaitons, 鈥榩olitical鈥� impact / pressure
the impact of just culture on patient safety and safety of different stakeholders
corrective and preventive actions within healthcare organisations
licensing / accreditation of healthcare services and organisations
monitoring of health care outputs at the organisational level
monitoring and evaluation of outcomes at the national level
regulation of healthcare professionals
The legal and ethical frameworks for safety within the healthcare ecosystem
ethical aspects related to stakeholder safety at the different healthcare levels
disclosure and protection of healthcare professionals
disclosure to patients and its impact, defensive approaches
use of adverse events for legal purposes
conflicting interests of stakeholders and protection of stakeholders
anonymisation of adverse events reports
compensation systems / legislation
occupational health and safety legislation in healthcare
professional indemnity and insurance
Institutional support initiatives and intervention programs
second victim support programs for healthcare workers involved in
patient safety incidents and peer support programs
employee support initiatives, employee safety programs,
burnout of healthcare professionals and sustainability of healthcare systems
creating awareness, development, resources and design, implementation, evaluation, sustainability
learning from institutional and peer support programs in other countries e.g. RISE, MISE, PSU (Germany)
role of professional associations,
role and impact of trade unions
protection of the initiative through the legal framework
learning from safety initiatives in other areas such as aviation
escalation of support systems: peer support, crisis intervention,
Dealing and coping with situations of adverse events
possibility of working in simulation centres
use of case studies from practice
addressing adverse events within the hospital environment
training in a safe environment
seeking, receiving and accepting emotional support, coping strategies
giving and receiving peer support
emotional first aid training
Main Reading List
Vincent, C. (2001). Clinical Risk Management. 2nd Edition, BMJ Books, London
Vincent, C. (2010). Patient Safety. Wiley Books, London
Waterson, P. (Ed.). (2018). Patient safety culture: theory, methods and application. CRC Press
Goeschel, C. A., Wachter, R. M., & Pronovost, P. J. (2010). Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges. Chest, 138(1), 171-178.
Supplementary Reading List
Beir茫o, G., Patr铆cio, L. and Fisk, R.P. (2017), ""Value cocreation in service ecosystems: Investigating health care at the micro, meso, and macro levels"", Journal of Service Management, Vol. 28 No. 2, pp. 227-249. https://doi.org/10.1108/JOSM-11-2015-0357
Buttigieg, S. C., Tomaselli, G., Byers, V., Cassar, M., Tjerbo, T., & Rosano, A. (2019). Corporate social responsibility and person-centered care: a scoping review. Journal of Global Responsibility.
Caldwell, S. and Mays, N., 2012, Studying policy implementation using a macro, meso and micro frame analysis: the case of the Collaboration for Leadership in Applied Health Research & Care (CLAHRC) programme nationally and in North West London, Health Research Policy and Systems, 10.32. doi: 10.1186/1478-4505-10-32
Chandler, J.D. and Vargo, S.L. (2011) Contextualisation and value-in-context: how context frames exchange鈥�, Marketing Theory, 11(1) 35-49. DOI: 10.1177/1470593110393713-
Clarkson, M.D., Haskell, H., Hemmelgarn, C, Skolnil, P.J. 2019 Abandon the term 鈥渟econd victim鈥� British Medical Journal, 364:I1233 doi: 10.1136/bmj.I1233
COST (European Cooperation in Science and Technology) https://www.cost.eu/ [accessed 21052023]
ERNST COST Action CA 19113 (The European Researchers鈥� Network Working on Second Victims) https://cost-ernst.eu/ [accessed 21052023]
ERNST, The European Researchers鈥� Network Working on Second Victims, ERNST Training Manual. ERNST- COST Action CA19113, https://trainingmanual.cost-ernst.eu/
Finney, R.E., Czinski S., Fjerstad, K., Arteaga, G.M,, Weaver, A.L,, Riggan, K.A,, Allysse, M.A,, Long, ME,, Torbenson V.E,, Rivera-Chiauzzi E.Y. 2021. Evaluation of a Second Victim Peer Support Program on Perceptions of Second Victim Experiences and Supportive Resources in Paediatric Clinical Specialties Using the Second Victim Experience and Support Tool (SVEST), Journal of Paediatric Nursing, 61 312-317 https:/doi.ord/10.1016/j.pedn2021.06.023
Hughes, G., Shaw, S.E., Greenhalgh, T. 2020. Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts, The Milbank Quarterly, pp. 1-47.
Liukka, M., Steven, A., Flores Vizcaya Moreno, M., Sara-aho, A.M., Khakurel, J., Pearson, P., Turunen, H., Tella, S. (2020) Action after Adverse Events in Healthcare: An Integrative Literature Review, International Journal of Public Health, 17, 4717; doi:10.3390/ijerph17134717
Mira, J.J. 2023 Understanding Honest Mistakes, Second Victims and Just Culture for Patient Safety, Journal of Healthcare Quality Research, 38, 359-261. https://doi.org/10.1016/j.jhqr.2023.08.001
Mira, J.J., Lorenzo, S., Carillo, I., Ferrus, L., Perez-Perez, P., Iglesias, F., Silvestre, C., Oliviera, G., Zavala, E., Nuno-Solinis, R., Maderuelo-Fernandez, J.A., Vitaller, J., Astier, P. 2015. Interventions in health organisations to reduce the impact of adverse events in second and third victims, BMC Health 福利在线免费 Research, 15: 341 doi 10.1186/s12913-015-0994-x
Muethel., M., Frei, C., and Hollensbe, E. (2023) Erring Professionals as Second Victims: Grappling with Guilt and Identity in the Aftermath of Error, Academy of Management Journal, https://doi.org/10.5465/amj.2021.1132
Rafter, N., Hickey, A., Condell, S., Conroy, R., O'Connor, P., Vaughan, D., Williams, D. (2015) Adverse events in healthcare: learning from mistakes. QJM: An International Journal of Medicine, Volume 108, Issue 4, April 2015, Pages 273鈥�277 https://doi.org/10.1093/qjmed/hcu145
Russ, M.J. (2017) Correlates of the third victim phenomenon, Psychiatric Quarterly, 88:917-920. Doi.10.1007/s11126-017-9511-1
Sanchez-Garcia, A., Saurin-Moran, P.J., Carrillo, I., Tella, S., Polluste, K., Srulovici, E., Buttigieg, S.C., Mira, J.J. (2023) Patient safety topics, especially the second victim phenomenon, are neglected in undergraduate medical and nursing curricula in Europe: an online observational study. BMC Nursing 22: 283 https://doi.org/10.1186/s12912-023-01448-w
Sawatzky, R., Kwon, J.Y., Barclay, R., Chauhan, C., Frank, L., van den Hout, W.B., Nielsen, L.K., Nolte, S., Sprangers, M.A.G, the Response Shift 鈥� in Sync Working Group. 2021. Quality of Life Research, 30:3343-3357. https://doi.org/10.1007/s11136-021-02766-9.
Scott, S.D., Hirschinger, L.E., Cox, K.R., McCoig, M., Brandt, J., Hall, L.W. (2009) The natural history of recovery for the healthcare provider 鈥渟econd victim鈥� after adverse patient events, Quality and Safety in Health Care, 18:325-330 doi: 10.1136/qshc.2009.032870
Seys, D., Wu, A.W., Van Gerven, E., Vleugels, A., Euweman., M., Panella, M., Scott, S.D., Conway, J., Sermeus, W., Vanhaecht, K. (2012) Health Care Professionals as Second Victims after adverse events: A systematic review, Evaluation and the Health Professions, 36(2) 135-162 doi: 10.1177/0163278712458918
Treiber, L.A. and Jones, J.H. (2018) After the medication error: recent nursing graduates鈥� reflections on adequacy of education, Journal of Nursing Education, 57(5) 275 鈥� 280 doi:10.3928/01484834-20180420-04
Tumelty, M.E. (2021) Exploring the emotional burdens and impact of medical negligence litigation on the plaintiff and medical practitioner: insights from Ireland. Legal Studies, 41, 633-656.doi:10.1017/lst.2021.20
Tumelty, M.E. (2021) The Second Victim: a contested term? Journal of Patient Safety, 17 (8) doi:10.1097/PTS.0000000000000558
Tumelty, M.E., (Criminal responsibility for medical injury: as helpful or harmful mechanism for patient safety? Medical Law International, 21(4) 289-292 doi:10.1177/09685332211064806
Valentijn, P.P. 2017 Rainbow of Chaos: A study into the Theory and Practice of Integrated Primary Care. International Journal of Integrated Care, 16(2): 3, 1-4 http//dx.doi.org/10.5334/ijic.2465
Vanhaecht, K., Seys, D., Schouten, L., Bruyneel, L., Coeckelberghs, E., Panella, M., Zeeman, G., (2019) Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands BMJ Open 9:e029923 doi:10.1136/bmjopen-2019-029923
Vanhaecht, K., Seys, D., Russotto, S., Strametz, R., Mira, J., Sigurgeirsdottir, S., Wu, A.W., Polluste K., Popovici, D.G., Sfetcu, R., Kurt, S., Panella, M. (2022) An Evidence and Consensus-Based Definition of Second Victim: A strategic topic in healthcare quality, patient safety, person-centredness and human resource management, International Journal of Environmental Research and Public Health, 19(24), 16869 https://doi.org/10.3390/ijerph192416869
Watermann, A.D., Garbutt, J., Hazel, E., Dunagan, W.C., Levinson, W., Fraser, V.J. and Gallagher, T.H. (2007) The emotional impact of medical errors on practising physicians in the United States and Canada. Joint Commission Journal on Quality and Patient Safety, 33(8), 467-476. https://doi.org/10.1016.S1553-7250(07)33050-X
Wu, A.W., (2000) Medical error: the second victim, The doctor who makes the mistake needs help too, British Medical Journal, 320, 726-727.
Wu, A.W. and McCay, L. (2012) Medical error: the second victim, British Journal of Hospital Medicine, October 2012, Vol 73, 10 C146- C148.
Zhang, X., Li, Q., Guo, Y., Lee, S.Y., (2019) From organisational support to second victim-related distress: role of patient safety culture. Journal of Nursing Management, 27: 1818-1825. doi:10.1111/jonm.1288.
Please check your eligibility to join this short course and time-tabling details with the Faculty of Health Sciences. The short course will only be delivered subject to a minimum number of applications being received.
To provide knowledge of the impact of adverse events on patients, healthcare workers, health provider organisations and the wider ecosystem
To provide knowledge of factors affecting the victims phenomenon including national legislation and regulation, patient safety culture, organisational culture across the healthcare ecosystem
To provide knowledge and develop skills for the development and application of different approaches to prevent and tackle adverse events at the macro, meso and micro level which support safety of the different stakeholders across the ecosystem
To nurture skill and behaviour which support the management and dealing with adverse events and enforces the adoption of a just culture across the ecosystem
To provide knowledge and develop skills to deal with legal implications related to adverse events
To provide knowledge and teach skill and behaviour for the stakeholders to act ethically
Learning Outcomes: Knowledge and Understanding
By the end of the study-unit the student will be able to:
implement practice which secures patient safety,
predict and identify risks and incident causes and impacts
design for emergency preparedness and corrective and preventive action
apply corrective and preventive actions to minimize the impact from adverse events
classify and explain the concepts of first, second and third victims and relationships between them
classify adverse events, mistakes and near-misses and variables / factors concerned
identify the consequences of adverse events in patients, significant others, healthcare professionals, healthcare management and organisations and teams
categorise and analyse different cultural and legal contexts and factors: safety culture, just culture, tort, litigation, approach for dealing with mistakes
roleplay, appraise and implement potential interventions to support patients and significant others,
roleplay interventions to support healthcare workers when they are impacted by adverse events, crises and burn out
appraise and critique factors that help health organisations to maintain a safety climate and avoid medical errors
demonstrate cultural differences in the interpretation of meaning of errors and how to deal with them in different countries and inter-profesionallly
apply the correct attitude and behaviour when dealing with all stakeholders including patients and their relatives after an adverse event
appraise the relevance of the legal framework on safety and practice
practice psychological safety and demonstrate ability to seek help
implement occupational health and safety policies
describe and discuss professional insurance and indemnity, professional code of practice and code of ethics
demonstrate ability to deal with adverse events considering the perspective of the different stakeholders across the ecosystem
Learning Outcomes: Skills
By the end of the study-unit the student will be able to:
implement practice which secures patient safety,
predict and identify risks and incident causes and impacts
design for emergency preparedness and corrective and preventive action
apply corrective and preventive actions to minimize the impact from adverse events
classify and explain the concepts of first, second and third victims and relationships between them
classify adverse events, mistakes and near-misses and variables / factors concerned
identify the consequences of adverse events in patients, significant others, healthcare professionals, healthcare management and organisations and teams
categorise and analyse different cultural and legal contexts and factors: safety culture, just culture, tort, litigation, approach for dealing with mistakes
roleplay, appraise and implement potential interventions to support patients and significant others,
roleplay interventions to support healthcare workers when they are impacted by adverse events, crises and burn out
appraise and critique factors that help health organisations to maintain a safety climate and avoid medical errors
demonstrate cultural differences in the interpretation of meaning of errors and how to deal with them in different countries and inter-profesionallly
apply the correct attitude and behaviour when dealing with all stakeholders including patients and their relatives after an adverse event
appraise the relevance of the legal framework on safety and practice
practice psychological safety and demonstrate ability to seek help
implement occupational health and safety policies
describe and discuss professional insurance and indemnity, professional code of practice and code of ethics
demonstrate ability to deal with adverse events considering the perspective of the different stakeholders across the ecosystem
Non EU Applicants:
EUR850
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Micro-credentials offer the possibility of providing flexible learning pathways to respond to evolving needs and new developments, thus enabling students to tailor their studies to their needs. Micro-credentials may be combined or transferred into larger credentials, such as certificates, diplomas and degrees, provided that the relevant programme requirements are met. Applicants wishing to transfer micro-credentials to a programme of study are encouraged to seek the advice of the relevant academic entity.
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