Qualitative Study About the Experiences of Colleagues of Health Professionals Involved in an Adverse Event.

OBJECTIVES: Identify what occurs among health-care providers (HCPs) after an adverse event (AE) and what colleagues could do to help them. METHOD: A qualitative study with participation by physicians and nurses from hospitals and primary care facilities. RESULTS: Fifteen HCPs and 12 health professionals with quality management responsibilities with between 8 and 30 years of experience participated; 15 (56%) were physicians (9 general practitioners, 3 surgeons, 2 intensivists, and 1 from an emergency unit), and 12 (44%) were nurses (5 worked in primary care and 7 in hospitals). There was consensus that second victims require support from colleagues and management; however, instead, many times they perceive rejection. They experience repetitive thoughts, fear, and loneliness. Formal channels of information favor the implementation of improvements. Health-care providers reported that information about measures for preventing a new adverse event is inaccessible, whereas management said that a change in behavior was necessary to promote a culture of safety. Common informal channels were the hallways and cafeteria. Reactions by colleagues of second victims were of surprise and to avoid involvement. CONCLUSIONS: Organized plans and protocols about what to do to help HCPs after an AE are uncommon. Formal channels of information mitigate rumors and misinformation. Informal channels hinder learning from the experience and strengthening the culture of safety, and they encourage incidents to be hidden. Approaches that permit HCPs involved in an AE to speak about what has happened offer a positive response to their emotional needs.

Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations.

PURPOSE: To summarize the knowledge about the aftermath of adverse events (AEs) and develop a recommendation set to reduce their negative impact in patients, health professionals and organizations in contexts where there is no previous experiences and apology laws are not present. DATA SOURCES: Review studies published between 2000 and 2015, institutional websites and experts' opinions on patient safety. STUDY SELECTION: Studies published and websites on open disclosure, and the second and third victims' phenomenon. Four Focus Groups participating 27 healthcare professionals. DATA EXTRACTION: Study characteristic and outcome data were abstracted by two authors and reviewed by the research team. RESULTS OF DATA SYNTHESIS: Fourteen publications and 16 websites were reviewed. The recommendations were structured around eight areas: (i) safety and organizational policies, (ii) patient care, (iii) proactive approach to preventing reoccurrence, (iv) supporting the clinician and healthcare team, (v) activation of resources to provide an appropriate response, (vi) informing patients and/or family members, (vii) incidents' analysis and (viii) protecting the reputation of health professionals and the organization. CONCLUSION: Recommendations preventing aftermath of AEs have been identified. These have been designed for the hospital and the primary care settings; to cope with patient's emotions and for tacking the impact of AE in the second victim's colleagues. Its systematic use should help for the establishment of organizational action plans after an AE.

The Second Victim Phenomenon After a Clinical Error: The Design and Evaluation of a Website to Reduce Caregivers' Emotional Responses After a Clinical Error.

BACKGROUND: Adverse events (incidents that harm a patient) can also produce emotional hardship for the professionals involved (second victims). Although a few international pioneering programs exist that aim to facilitate the recovery of the second victim, there are no known initiatives that aim to raise awareness in the professional community about this issue and prevent the situation from worsening. OBJECTIVE: The aim of this study was to design and evaluate an online program directed at frontline hospital and primary care health professionals that raises awareness and provides information about the second victim phenomenon. METHODS: The design of the Mitigating Impact in Second Victims (MISE) online program was based on a literature review, and its contents were selected by a group of 15 experts on patient safety with experience in both clinical and academic settings. The website hosting MISE was subjected to an accreditation process by an external quality agency that specializes in evaluating health websites. The MISE structure and content were evaluated by 26 patient safety managers at hospitals and within primary care in addition to 266 frontline health care professionals who followed the program, taking into account its comprehension, usefulness of the information, and general adequacy. Finally, the amount of knowledge gained from the program was assessed with three objective measures (pre- and posttest design). RESULTS: The website earned Advanced Accreditation for health websites after fulfilling required standards. The comprehension and practical value of the MISE content were positively assessed by 88% (23/26) and 92% (24/26) of patient safety managers, respectively. MISE was positively evaluated by health care professionals, who awarded it 8.8 points out of a maximum 10. Users who finished MISE improved their knowledge on patient safety terminology, prevalence and impact of adverse events and clinical errors, second victim support models, and recommended actions following a severe adverse event (P<.001). CONCLUSIONS: The MISE program differs from existing intervention initiatives by its preventive nature in relation to the second victim phenomenon. Its online nature makes it an easily accessible tool for the professional community. This program has shown to increase user's knowledge on this issue and it helps them correct their approach. Furthermore, it is one of the first initiatives to attempt to bring the second victim phenomenon closer to primary care.

Qué, quién, cuándo, dónde y cómo informar a los pacientes tras un evento adverso: un estudio cualitativo / What, who, when, where and how to inform patients after an adverse event: a qualitative study

OBJETIVOS: Explorar experiencias y recomendaciones para informar adecuadamente al paciente que ha sufrido un evento adverso (EA) en un contexto donde no se cuenta con leyes de disculpa. MÉTODO: Estudio cualitativo basado en las técnicas de grupo focal y Metaplan. Este estudio se realizó con médicos y enfermeros de atención primaria y hospitales del sistema público de salud en España. RESULTADOS: Participaron 27 profesionales con entre 8 y 30 años de experiencia, 15 (56%) médicos y 12 (44%) enfermeros; 13 (48%) trabajaban en hospitales. Existió consenso en cuanto a cómo (lenguaje claro, honestidad), dónde (evitar pasillos, en espacio acondicionado, con intimidad) y cuándo informar (con agilidad pero sin precipitación, al disponer de suficiente información y tras reflexionar sobre la forma más adecuada según la naturaleza del EA). Existió controversia en cuanto a qué decirle al paciente tras EA con consecuencias graves, dudas sobre en qué casos se debía informar de lo sucedido; quién debía informar (si el profesional más directamente implicado en el EA u otro profesional, el papel del equipo directivo o de los mandos intermedios); y sobre en qué casos una disculpa podía suponer un problema. CONCLUSIONES: La naturaleza del EA determina quién debe conversar con el paciente en hospitales y atención primaria. Debe meditarse, según los casos, la forma más apropiada para trasladarle una disculpa al paciente. Una actuación temprana, directa, empática, proactiva y acompañada de información sobre una compensación por el daño sufrido contribuiría a reducir el número de reclamaciones

OBJECTIVE: To explore suggestions and recommendations for conducting open disclosure with a patient after an adverse event in a setting without professionals' legal privileges. METHOD: Qualitative study conducting focus groups/Metaplan. This study was conducted with physicians and nurses from Primary Care and Hospitals working in the public health system in Spain. RESULTS: Twenty-seven professionals were involved 8-30 years of experience, 15 (56%) medical and 12 (44%) nurses, 13 (48%) worked in hospitals. Consensus was obtained on: how (honesty and open and direct language), where (avoid corridors, with privacy), and when to disclose (with agility but without precipitation, once information is obtained, and after reflecting on the most suitable according to the nature of the AE). There was controversy as to what to say to the patient when the AE had serious consequences and doubts about what type of incidents must be reported; who should be required to disclose (the professional involved in the AE or other professional related to the patient, the role of the staff and the management team); and in which cases an apology can be a problem. CONCLUSIONS: The severity of the AE determines who should talk with the patient in both hospital and primary care. The most appropriate way to convey an apology to the patient depends of the AE. An early, direct, empathetic and proactive action accompanied by information about compensation for the harm suffered could reduce the litigation intention

What, who, when, where and how to inform patients after an adverse event: a qualitative study. / Qué, quién, cuándo, dónde y cómo informar a los pacientes tras un evento adverso: un estudio cualitativo.

OBJECTIVE: To explore suggestions and recommendations for conducting open disclosure with a patient after an adverse event in a setting without professionals' legal privileges. METHOD: Qualitative study conducting focus groups/Metaplan. This study was conducted with physicians and nurses from Primary Care and Hospitals working in the public health system in Spain. RESULTS: Twenty-seven professionals were involved 8-30 years of experience, 15 (56%) medical and 12 (44%) nurses, 13 (48%) worked in hospitals. Consensus was obtained on: how (honesty and open and direct language), where (avoid corridors, with privacy), and when to disclose (with agility but without precipitation, once information is obtained, and after reflecting on the most suitable according to the nature of the AE). There was controversy as to what to say to the patient when the AE had serious consequences and doubts about what type of incidents must be reported; who should be required to disclose (the professional involved in the AE or other professional related to the patient, the role of the staff and the management team); and in which cases an apology can be a problem. CONCLUSIONS: The severity of the AE determines who should talk with the patient in both hospital and primary care. The most appropriate way to convey an apology to the patient depends of the AE. An early, direct, empathetic and proactive action accompanied by information about compensation for the harm suffered could reduce the litigation intention.

Design and Testing of BACRA, a Web-Based Tool for Middle Managers at Health Care Facilities to Lead the Search for Solutions to Patient Safety Incidents.

BACKGROUND: Lack of time, lack of familiarity with root cause analysis, or suspicion that the reporting may result in negative consequences hinder involvement in the analysis of safety incidents and the search for preventive actions that can improve patient safety. OBJECTIVE: The aim was develop a tool that enables hospitals and primary care professionals to immediately analyze the causes of incidents and to propose and implement measures intended to prevent their recurrence. METHODS: The design of the Web-based tool (BACRA) considered research on the barriers for reporting, review of incident analysis tools, and the experience of eight managers from the field of patient safety. BACRA's design was improved in successive versions (BACRA v1.1 and BACRA v1.2) based on feedback from 86 middle managers. BACRA v1.1 was used by 13 frontline professionals to analyze incidents of safety; 59 professionals used BACRA v1.2 and assessed the respective usefulness and ease of use of both versions. RESULTS: BACRA contains seven tabs that guide the user through the process of analyzing a safety incident and proposing preventive actions for similar future incidents. BACRA does not identify the person completing each analysis since the password introduced to hide said analysis only is linked to the information concerning the incident and not to any personal data. The tool was used by 72 professionals from hospitals and primary care centers. BACRA v1.2 was assessed more favorably than BACRA v1.1, both in terms of its usefulness (z=2.2, P=.03) and its ease of use (z=3.0, P=.003). CONCLUSIONS: BACRA helps to analyze incidents of safety and to propose preventive actions. BACRA guarantees anonymity of the analysis and reduces the reluctance of professionals to carry out this task. BACRA is useful and easy to use.

Interventions in health organisations to reduce the impact of adverse events in second and third victims.

BACKGROUND: Adverse events (AE) are also the cause of suffering in health professionals involved. This study was designed to identify and analyse organization-level strategies adopted in both primary care and hospitals in Spain to address the impact of serious AE on second and third victims. METHODS: A cross-sectional study was conducted in healthcare organizations assessing: safety culture; health organization crisis management plans for serious AE; actions planned to ensure transparency in communication with patients (and relatives) who experience an AE; support for second victims; and protective measures to safeguard the institution's reputation (the third victim). RESULTS: A total of 406 managers and patient safety coordinators replied to the survey. Deficient provision of support for second victims was acknowledged by 71 and 61% of the participants from hospitals and primary care respectively; these respondents reported there was no support protocol for second victims in place in their organizations. Regarding third victim initiatives, 35% of hospital and 43% of primary care professionals indicated no crisis management plan for serious AE existed in their organization, and in the case of primary care, there was no crisis committee in 34% of cases. The degree of implementation of second and third victim support interventions was perceived to be greater in hospitals (mean 14.1, SD 3.5) than in primary care (mean 11.8, SD 3.1) (p < 0.001). CONCLUSIONS: Many Spanish health organizations do not have a second and third victim support or a crisis management plan in place to respond to serious AEs.

The aftermath of adverse events in Spanish primary care and hospital health professionals.

BACKGROUND: Adverse events (AEs) cause harm in patients and disturbance for the professionals involved in the event (second victims). This study assessed the impact of AEs in primary care (PC) and hospitals in Spain on second victims. METHODS: A cross-sectional study was conducted. We carried out a survey based on a random sample of doctors and nurses from PC and hospital settings in Spain. A total of 1087 health professionals responded, 610 from PC and 477 from hospitals. RESULTS: A total of 430 health professionals (39.6%) had informed a patient of an error. Reporting to patients was carried out by those with the strongest safety culture (Odds Ratio -OR- 1.1, 95% Confidence Interval -CI- 1.0-1.2), nurses (OR 1.9, 95% CI 1.5-2.3), those under 50 years of age (OR 0.7, 95% CI 0.6-0.9) and primary care staff (OR 0.6, 95% CI 0.5-0.9). A total of 381 (62.5%, 95% CI 59-66%) and 346 (72.5%, IC95% 69-77%) primary care and hospital health professionals, respectively, reported having gone through the second-victim experience, either directly or through a colleague, in the previous 5 years. The emotional responses were: feelings of guilt (521, 58.8%), anxiety (426, 49.6%), re-living the event (360, 42.2%), tiredness (341, 39.4%), insomnia (317, 38.0%) and persistent feelings of insecurity (284, 32.8%). In doctors, the most common responses were: feelings of guilt (OR 0.7 IC95% 0.6-0.8), re-living the event (OR 0.7, IC95% o.6-0.8), and anxiety (OR 0.8, IC95% 0.6-0.9), while nurses showed greater solidarity in terms of supporting the second victim, in both PC (p = 0.019) and hospital (p = 0.019) settings. CONCLUSIONS: Adverse events cause guilt, anxiety, and loss of confidence in health professionals. Most are involved in such events as second victims at least once in their careers. They rarely receive any training or education on coping strategies for this phenomenon.

Grupos relacionados con el diagnóstico e intensidad de cuidados de enfermería: variabilidad y homogeneidad de los cuidados enfermeros / Diagnosis related groups and intensity of nursing care: variability and homogeneity of nursing care

Objetivos: Determinar la variabilidad de la intensidad de los cuidados de enfermería en pacientes hospitalizados, en función del día de estancia, para cada grupo relacionado con el diagnóstico (GRD). Valorar si los GRD estudiados permiten distinguir grupos homogéneos en cuanto a la intensidad de los cuidados. Predecir la intensidad de los cuidados de enfermería que deben planificarse para un determinado paciente y día de estancia concreto para cada GRD. Relacionar la intensidad de los cuidados de enfermería y el peso relativo de cada GRD. Métodos: En una cohorte de pacientes ingresados entre los meses de febrero a julio del año 1997, se estudió la intensidad de cuidados de enfermería. La población de estudio fueron 600 pacientes ingresados en el Consorci de l'Hospital de la Creu Roja de l'Hospitalet de Llobregat (CHCRH), que al alta se clasificaron en uno de los 12 GRD más frecuentes. La información utilizada se obtuvo a partir de la historia clínica y de las hojas de registro del sistema PRN (Project Research in Nursing) para la medida de la intensidad de cuidados. Se recogieron datos de identificación del paciente, actividades de cuidados de enfermería y diagnóstico de enfermería. Para cada GRD, se calculó la media, la mediana, la desviación estándar y el coeficiente de variabilidad (CV) desviación estándar/media) de la intensidad de cuidados de enfermería correspondiente. Se aplicó un análisis de la variancia para medidas repetidas al estudio de la variabilidad del nivel de cuidados de enfermería en función del día de estancia. Se analizó la homogeneidad de cada GRD mediante un ANOVA para medidas repetidas, con un factor intergrupos (GRD considerados) y un factor intragrupo (día de estancia). Para la predicción de la intensidad de los cuidados de enfermería se presentan para los 7 o 10 primeros días de estancia, la desviación estándar, la media y el intervalo de confianza del 95 por ciento de la media de la intensidad de los cuidados de enfermería para cada GRD. Resultados: El GRD 014 (trastorno específico cerebrovascular) es el que presenta el CV más elevado en función del día de estancia y también es el GRD con una mayor variabilidad en la mayoría de los componentes de cuidados. El GRD 014 es el que tiene la intensidad de cuidados de enfermería más elevada (4.404 min) mientras que el peso relativo es similar al del GRD 122 (IAM) que tiene una intensidad de cuidados de casi la mitad. Discusión: Los elevados coeficientes de variabilidad de la intensidad de cuidados de enfermería según el día de estancia, que presentan la mayoría de los procesos estudiados, nos conduce a creer que la incorporación de trayectorias clínicas reduciría la variabilidad de la práctica clínica y permitiría planificar mejor la adjudicación de los recursos de enfermería. Al analizar la homogeneidad de la intensidad de cuidados de cada GRD para el total de cuidados o sus componentes, parece que los cuidados básicos (higiene, eliminación, alimentación, etc.) son los que tienen una mayor influencia sobre la variabilidad. La intensidad total de cuidados de cada GRD no tiene una relación directa con su peso relativo (AU)

Grupos relacionados con el diagnóstico e intensidad de cuidados de enfermería: estudio descriptivo / Diagnosis related groups and intensity of nursing care: descriptive study

Objetivo: Determinar la intensidad y tipología de los cuidados de enfermería para determinados Grupos Relacionados con el Diagnóstico (GRD). Métodos: En una cohorte de pacientes ingresados entre los meses de febrero y julio del año 1997, se estudió la intensidad de cuidados de enfermería. La población de estudio fueron 600 pacientes ingresados en el Consorcio de l'Hospital de la Creu Roja de L'Hospitalet de Llobregat (CHCRH), que al alta se clasificaron en uno de los 12 GRD más frecuentes.La información utilizada se obtuvo a partir de la historia clínica y de las hojas de registro del sistema PRN (Project Research in Nursing). Se recogieron datos de identificación del paciente, actividades de cuidados de enfermería y diagnósticos de enfermería. Para el análisis descriptivo de las variables categóricas se obtuvieron frecuencias, se aplicó la prueba de la normalidad de Kolgomorov para el análisis descriptivo de las variables continuas. Para la comparación de variables continuas se aplicó la prueba de la t de Student o la prueba de la U de Mann-Whitney si no seguían una distribución normal. Resultados: Se incluyeron en el estudio 600 procesos, de los cuales el GRD 014 (trastorno específico cerebrovascular) obtuvo la mayor intensidad de cuidados y el GRD 039 (intersección del cristalino con o sin vitrectomía) la menor. En casi todos los GRD la intensidad en los cuidados fue significativamente (p < 0,05) mayor en el grupo de edad igual o superior a 65 años. Al realizar el análisis según componente de cuidados y por grupo de edad, tomando como unidad de análisis las estancias o días, se observó que los grupos de mayor edad presentaban en todos los componentes de cuidados la intensidad de cuidados de enfermería más elevada. Conclusión: Para casi todos los GRD, los cuidados de enfermería son más elevados en los grupos de edad mayores. Los GRD con una estancia media superior presentan la mayor intensidad de cuidados (AU)

Ancianos con sida. Reflexiones a propósito de un caso / Elderly suffering from AIDS: reflections based on a case

Cuando hablamos de SIDA, todavía hoy, difícilmente lo asociamos con los ancianos. Sin embargo, la experiencia asistencial está demostrando que los casos son cada vez más numerosos dentro de este grupo de población considerado como la tercera edad. No olvidemos que la sexualidad es una experiencia personal que puede practicarse toda la vida (y que no se limita a los jóvenes) y que la prevención es necesaria en todos los casos. Por eso es interesante acompañar a las autoras en su reflexión al respecto, utilizando para ello un caso real. Probablemente habrá que cambiar los esquemas establecidos y considerar a este grupo de población como necesitado de información sobre las posibilidades de contagio. También será imprescindible realizar diagnósticos más rápidos y desarrollar medidas educativas y de formación continuada para que los ancianos sean considerados como susceptibles de padecer la enfermedad y mejorar la atención que les prestamos. El Sida no discrimina. Por eso nosotros tampoco podemos hacerlo (AU)