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Second victim programs within the hospital setting: an extensive literature review with practice recommendations

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Second victim programs within the hospital setting: an extensive literature review with practice recommendations

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SECOND VICTIM PROGRAMS WITHIN THE HOSPITAL SETTING:
AN EXTENSIVE LITERATURE REVIEW
WITH PRACTICE RECOMMENDATIONS
by
Monica S. Yeung

A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE

May 2021
ii

The following manuscript was contributed to in equal parts by Chelsie J. Arnold, Marie K.
Stortz, and Monica S. Yeung.

iii

Dedication
The authors would like to dedicate this work to all second victims, past and present. We hope
that through continued research and education, a more comprehensive and proactive approach to
supporting each other can be identified.

iv

Acknowledgements
The authors would like to acknowledge and thank their chair committee members
Michele Gold, PhD, CRNA, Erica McCall, MSN, MPH, CRNA, and Elizabeth Bamgbose, PhD,
CRNA. Their guidance, mentorship, and expertise throughout the entirety of this literature
review was paramount to the identification of new practice recommendations and the authors
sincerely thank them for their contributions.
The author wishes to acknowledge the support from her husband, Stephen Yeung,
throughout the Doctorate of Nurse Anesthesia Practice program at the University of Southern
California. The author also wishes to acknowledge family support from Bruno and Anna Stoch,
and Peter and Sandra Yeung. All the support and encouragement from the author’s husband and
family is what made it possible for achieving this goal.

v

Table of Contents

Dedication………………………………………………………………………………………...iii
Acknowledgements……………………………………………………………………………….iv
List of Tables …………………………………………………………………………………….vii
List of Figures…………………………………………………………………………………...viii
Abstract…………………………………………………………………………………...………ix
Chapter 1 …………………………………………………………………………………………..1
Introduction ………………………………………………………………………………..1
Purpose…………………………………………………………………………………….2
Background ………………………………………………………………………………..3
Chapter 2 …………………………………………………………………………………………..5
Literature Review………………………………………………………………………….5
Second Victim Programs….………………………………………………………………5
Peer Support Team (PST)/ Medically Induced Trauma Support Services (MITSS)
- Brigham and Women’s Hospital ………………………………………………...5
ForYOU Team - University of Missouri Health Care (MUHC)…………………..7
YOU Matter - Nationwide Children’s Hospital (NCH)………………………….10
Resilience in Stressful Events (RISE) - John Hopkins Hospital (JHH)………….11
Mitigating Impact in Second Victims (MISE) - Online Support Program ………13
Alternative Institutional Support Programs ……………………………………………...14
Code Lavender - University of California Health, San Diego (UCSD) …………14
Employee Assistance Program (EAP) …………………………………………...15
Chapter 3 …………………………………………………………………………………………17
Methods…………………………………………………………………………………..17
Gap Analysis ……………………………………………………………………..18
Chapter 4 …………………………………………………………………………………………19
Results ……………………………………………………………………………………19
vi

Chapter 5 …………………………………………………………………………………………21
Discussion ………………………………………………………………………………..21
Limitations ……………………………………………………………………….23
Conclusion ……………………………………………………………………….23
References ………………………………………………………………………………………..25
Appendix A: Modified PRISMA Flowchart ……………………………………………………..28
Appendix B: Literature Matrix …………………………………………………………………..29
Appendix C: Gap Analysis ………………………………………………………………………33

vii

List of Tables
Table 1: MITSS Downloadable Resources………………………………………………………. 7
Table 2: forYOU Team’s Eight Support Infrastructure Characteristics……………………….....8
Table 3: Second Victim Programs and Alternatives institutional Support Programs…………...22

viii

List of Figures

Figure 1: A Framework of Caring: The Scott Three-Tiered Interventional Model of Support…9

SECOND VICTIM PROGRAMS ix
Abstract

For healthcare professionals, witnessing or experiencing adverse patient outcomes is difficult.
Unanticipated patient harm or a medical error, resulting in patient injury, can have particularly
damaging effects to a healthcare provider’s well-being. This is referred to as the second victim
phenomenon and these providers can experience significant emotional distress impacting all
areas of their life. It is estimated that nearly half of all healthcare workers experience some form
of an adverse event, in which they become a second victim, at least once in their career, therefore
institutional based support is paramount. While hospitals may be implementing programs to
support second victims, these programs may be incomplete and ineffective in providing support.
The focus of this review is to identify essential elements of hospital-based second victim support
programs that are most representative of a comprehensive program. An extensive literature
search was electronically conducted, and a common theme identified throughout the literature
emphasized the need for hospital-based support programs utilizing peer supporters. The most
comprehensive program identified was the RISE (Resilience in Stressful Events) program at
John Hopkins Medical Center which institutionalized a short operational timeline, 24/7 peer
supporters, and tiered levels of professional support interventions. Second victim support
programs are essential to mitigating the potential devastating emotional distress a healthcare
worker can experience after an adverse event. It has become increasingly important that hospitals
offer comprehensive, timely support interventions to meet the needs of their employees who may
become second victims.
Keywords: second victim, second victim hospital program, second victim support, patient
safety program, critical incident, adverse event, medical error, employee assistance program

SECOND VICTIM PROGRAMS 1

Chapter 1
Introduction
For healthcare professionals, witnessing or experiencing imperfect patient outcomes is
difficult, but expected. However, unanticipated patient harm or being part of a medical error
resulting in patient injury-commonly referred to as an adverse event, can have particularly
damaging effects to a healthcare provider’s well-being. Current literature suggests that an
adverse event occurs in one of every seven patients (Seys et al., 2013). Chan, Khong, and Wang
(2016) describe that an adverse patient event in a healthcare setting occurs when an error is made
by a medical professional, or within the hospital system structure, resulting in an injury to a
patient. When an adverse event occurs, there are three potential victims: the first victim is the
patient and their family members, the second victim is the involved healthcare professionals and
associated team members, and the third victim is the involved organization or institution (Seys et
al., 2013). In 2000, Albert Wu introduced the term “second victim” to describe these individuals
and subsequently, literature on the effects of adverse events on healthcare providers conclude the
need for additional hospital-based support services for these second victims.
Frequently, second victims feel personally responsible when adverse patient outcomes
occur, typically questioning their skills and knowledge base (Scott et al., 2010). It is proposed
that half of all healthcare providers have experienced some level of the second victim
phenomenon over the course of their professional career (Edrees et al., 2011). According to Seys
et al. (2013), many healthcare providers struggle to identify adequate emotional support from
both their hospital organization and colleagues, resulting in internalization of their emotions
(Seys et al., 2013). The lack of support can be perpetuated if the organization reaches out to the
SECOND VICTIM PROGRAMS 2

patient first, prior to reaching out the provider, resulting in oversight of recognizing the
healthcare provider as a second victim (White et al., 2015).
Several studies have stressed the lack of institutional based support interventions to assist
healthcare professionals after an adverse event, while others have reported a lack of peer support
services available to healthcare providers to mitigate the second victim phenomenon (Burlison et
al., 2017). There is evidence in the literature of an urgent need for healthcare organizations to
invest in increasing the availability of quality support resources and comprehensive programs for
healthcare workers to lessen, or even prevent, the sequelae associated with any adverse event
(Scott et al., 2010). A few hospitals across the country, such as Brigham and Women’s Hospital,
University of Missouri Health Care (MUHC), John Hopkins Hospital (JHH), and Nationwide
Children’s Hospital (NCH) have developed, implemented, and published reports on
comprehensive second victim support programs with data indicating positive and effective
interventions.
Purpose
An investigation is warranted to discover the reasons behind second victims failing to
receive support from their institution after an adverse event, and to identify the best qualities
needed in hospital based second victim programs to support second victims. An extensive
literature review was conducted on published literature which aimed to identify the essential
elements that create a successful and comprehensive hospital-based second victim support
program. The following question guided the investigation: What are the essential quality
elements in hospital-based second victim programs to support health care providers when
involved in an adverse patient event? The population (P) within this extensive literature review
focuses on hospital-based second victim support programs within published literature. The
SECOND VICTIM PROGRAMS 3

intervention (I) identifies and assesses the essential elements of the hospital-based support
programs contributing to the high quality of support received by the second victim. The outcome
(O) of the literature review characterizes the elements of a hospital-based support program that
are distinguished as the most essential to creating a successful second victim support program,
meeting the needs of second victims, and recommend them as best practice.
The purpose of this literature review is to evaluate the currently available literature on
hospital based second victim support programs and identify the essential elements within those
programs that best assist second victims in their recovery process. Recommendations of
identified high quality, evidence-based support interventions, essential for successful mitigation
of the second victim phenomenon, can help guide future hospital leaders when implementing a
comprehensive second victim support program so they institute the most appropriate resources
available for those in need.
Background
In 2000, the term “second victim phenomenon” was pioneered by Dr. Albert Wu. Prior to
this, the phenomenon was only recognized as a spiritual, personal, professional, and social crisis.
Giving a name to an experience endured by many healthcare professionals sparked a rise in
research regarding the subject. Research by Dr. Wu states patients see their healthcare providers
as infallible, however providers occasionally make errors and therefore need support after these
mistakes (Wu, 2000). His findings suggested there was a need for formal support programs
tailored to the needs of the second victim.
Second victim phenomenon typically begins after a healthcare professional experiences
an adverse event resulting in harm to a patient (Wu, 2000). Immediately following the adverse
event, the second victim may experience confusion and is generally unable to comprehend the
SECOND VICTIM PROGRAMS 4

situation. It is also reported, after disclosing the error to the patient, organization, and colleagues,
the second victim may suffer from anxiety and guilt (Schroder, Edrees, Christensen, Jorgensen,
Lamont, Hvidt, 2018). The second victim may also encounter judgement and blame from
colleagues, thus enduring a lack of support within their social community (Schroder et al., 2018).
In the following days to weeks, the second victim may begin to report emotional detachment,
feelings of shame about the event, and symptoms of depression (Wu, 2000). These
manifestations of immense guilt stem from failing to prevent harm to their patients and breaking
the patient-provider relationship. Each provider is unique, therefore the timeframe in which an
individual can experience the second victim phenomenon may vary from provider to provider.
Progression of these symptoms without immediate intervention may result in burnout, further
depression, numbness towards their profession, and most severely, suicidal ideations (Pratt et al.,
2012).

SECOND VICTIM PROGRAMS 5

Chapter 2
Literature Review
After defining second victim emotions that follow an adverse event or a medical error, a
comprehensive literature review was conducted to identify hospital based second victim specific
support programs. Five second victim specific programs were identified: (a) Peer Support Team
(PST)/ Medically Induced Trauma Support Services (MITSS), (b) For YOU Team, (c) YOU
Matter, (d) Resilience in Stressful Events (RISE), and (e) Mitigating Impact in Second Victims
(MISE). Two additional programs identified, (a) Code Lavender and (b) Employee Assistance
Programs (EAP), offer support and resources to their healthcare workers without being second
victim specific.
Second Victim Programs
Peer Support Team (PST)/ Medically Induced Trauma Support Services (MITSS) -
Brigham and Women’s Hospital
An early and important peer support initiative was launched in 2006 by Dr. van Pelt. Van
Pelt identified healthcare professionals had become emotionally distant; leading and contributing
to a system in which the caregiver preserves the culture of blame and can become a second
victim (van Pelt, 2008). He identified a gap in support services (following a reported adverse
medical event) at Brigham and Women’s Hospital in Boston, paving the way for a pilot Peer
Support Team (PST) program. The strength of this pilot program was its ability to provide
readily available and easily accessible emotional support services by peers with an aim to
eliminate the associated stigmas and maintaining peer confidentiality (van Pelt, 2008). The PST
was developed in conjunction with the Medically Induced Trauma Support Services (MITSS)
program, founded by Linda Kenny, the patient in Dr. van Pelt’s own adverse medical event.
SECOND VICTIM PROGRAMS 6

In 1999, the patient, Linda Kenney, was admitted for a lower extremity procedure for
which a peripheral nerve block was part of the anesthetic plan (MITTS, 2017). Within minutes of
receiving the block, the patient went into cardiac arrest. After a successful resuscitation, the
patient felt the medical care team would not address the incident. Upon discharge from the
hospital, she was given information on how to follow up with her medical care team but was not
given information on emotional support after the trauma she and family members experienced.
Once home, the patient received a letter from the anesthesiologist who administered the
peripheral nerve block, Dr. van Pelt, acknowledging the impact the event had on the patient and
her family. During a surgical follow up appointment, Linda’s surgeon expressed emotions and
feelings of fear and anxiety toward the event. Linda realized the impact of this experience far
surpassed her and her family and postulated that other patients, and clinicians were not being
emotionally supported following adverse clinical events. She attributed this to a lack of
infrastructure for emotional support, fear of litigation, and healthcare culture. In order to change
the system, the online support foundation MITSS program was created (MITSS, 2017).
The MITSS program aims to provide a support network for patients, families, and
clinicians following an adverse event (MITSS, 2017). The MITSS foundation is a website-based
support tool offering educational videos and downloadable resources for healthcare providers
and institutions (Table1). Additionally, MITSS has deployable personnel available to make
institutional site visits as requested for additional support and evaluation. Together, the PST and
the MITSS programs are foundational second victim support programs to which other
institutions have expanded upon.

SECOND VICTIM PROGRAMS 7

Table 1: MITSS Downloadable Resources
“Title” of downloadable
MITSS resources
Description
1. “Toolkit for building a clinician
and staff support program”
❖ PDF checklist that aids the institution in
implementing a support program
2. “Organizational assessment tool
for clinician support”
❖ This document is designed to give the medical
organization a real-time picture of where it is in
the process of implementing a support program
3. “Staff Support Assessment”

❖ An assessment survey designed to measure the
staff’s perceptions about currently available
support interventions

4. “LEND document”
❖ This document provides valuable information
for medical staff when addressing the emotional
impact an adverse event may have on patients
and their family members
❖ Listening, Empathetic response, Needs
assessment, Direction to services

ForYOU Team - University of Missouri Health Care (MUHC)
In 2010, MUHC developed and published their protocol for deployment of a Second
Victim Rapid Response Team (SVRRT), collectively known as the forYOU Team (Scott et al.,
2010). The driving force behind this program came from a root cause analysis conducted by the
Office of Clinical Effectiveness (OCE) that supervised clinical outcomes (Scott et al., 2010). In
May 2006, the OCE recognized a pattern of health care providers emotionally suffering during
clinical-event investigations of unanticipated events (Scott et al., 2010). This new discovery
motivated MUHC to identify and understand health care providers’ suffering during these
SECOND VICTIM PROGRAMS 8

unanticipated events (Scott et al., 2010). The forYOU Team support network was created after
analysis of 898 returned surveys from faculty and staff at MUHC. From these second victim
experience surveys, 269 of the 898 faculty and staff members reported experiencing second
victim associated distress, such as anxiety, depression, and concern for the ability to perform the
health care provider’s job (Scott et al., 2010). Of those who identified as second victims, 40 staff
members and faculty additionally reported seriously contemplating leaving their job. Eighty-
three percent of the overall returned surveys provided narratives offering suggestions for support
interventions that could be implemented (Scott et al., 2010). Eight support characteristics
identified from the survey are included in Table 2.

Table 2: forYOU Team’s Eight Support Infrastructure Characteristics
Eight Support Infrastructure Characteristics of the forYOU team
1 Provide a short leave from the clinical area to allow the clinician to regain composure
2 Ensure a safe culture without blame
3 Educate clinicians about the second victim phenomenon and available support services
4 Ensure a debriefing period after an event takes place allowing for review and reflection
5 Ensure an internal support team is always available for clinicians
6 Ensure predictable follow-up with second victim post adverse event
7 Provide confidentiality
8 Provide individualized services to aid in second victim recovery
Note. Excerpted from (Scott et al., 2010)
These eight characteristics describe a support infrastructure to aid the second victim
recovery process at MUHC, and ultimately led to the creation of the MUHC support program
framework, A Framework of Caring: The Scott Three-Tiered Interventional Model of Support
SECOND VICTIM PROGRAMS 9

(Scott et al., 2010). This framework further built upon the original PST program, and within
three tiers, describes elements to be included in a second victim program (Figure 2).
Figure 1: A Framework of Caring: The Scott Three-Tiered Interventional Model of Support
Note. Used with permission from the forYOU team at MUhealth

Within this model, tier one aims to promote peer support at the unit or departmental level
and promotes primary emotional support. This tier addresses immediate accessibility following a
critical clinical event which could transpire into a second victim case. Tier two aims to provide
guidance and support by peers that have undergone special training to second victims through
individual or group support debriefings. At the tier two level, trained peer supporters can refer
second victims to other available resources if requested or deemed necessary. Tier three
identifies licensed professionals to provide counseling support services when the needed support
exceeds the capability of the peer supporters.
Scott et al. (2010) emphasized the importance of extensive team training through didactic
coursework, small-group scenario-based training, and simulation with their forYOU Team
members. Training topics are specific to second-victim literature and responses, high risk
SECOND VICTIM PROGRAMS 10

clinical situations, how and what to listen for, managing a one-on-one crisis intervention with a
peer, how to be in a support role, debriefing techniques, and their institution’s referral
procedures. Additionally, Scott et al. (2010) stressed the importance of having unit
administration, managers and clinical leaders involved in the training and availability process to
be able to assist with program oversight.
YOU Matter - Nationwide Children’s Hospital (NCH)
At Nationwide Children’s Hospital (NCH), a comprehensive peer support program called
YOU Matter was implemented after a system-wide survey revealed 30% of the responding
healthcare professionals reported experiencing second-victim related symptoms such as anxiety,
sleep disturbances, and contemplation of leaving the institution following an adverse event
(Merandi et al., 2017). The YOU Matter program was created following a review of the
MUHC’s forYOU program and in collaboration with the MUHC’s patient safety team. Six
strategic elements were identified for the YOU Matter program. The six elements included: (a)
identification of a core team, (b) executive sponsorship, (c) unit-based teams, (d) program
branding, (e) education and training, and (f) ensuring effectiveness (Merandi et al., 2017). The
YOU Matter program at NCH additionally adapted the Scott Three-Tiered Interventional Model
as part of their overall program structure.
The key differences identified between the forYOU Team at MUHC and the adaptation
for NCH’s YOU Matter, were a shorter operational timeline, more frequent peer training
sessions, and using electronic peer encounter forms for ongoing evaluation (Merandi et al.,
2017). NCH further identified that their peer support program enhanced sensitivity and the
psychological safety of their healthcare professionals. This overall aligned more directly with a
culture of safety for their patients (Merandi et al., 2017).
SECOND VICTIM PROGRAMS 11

The YOU Matter program leaders concluded peer support is the preferred method
identified by their medical professionals. The successful adaption of a comprehensive peer
support program within their institution, using the adapted MUHC framework, can be attributed
to the cooperation of their hospital administrators, the creation of a multidisciplinary core team,
active recruitment, program promotion, and the confidential documentation of events and
encounters to track program impact and effectiveness (Merandi et al., 2017).
Resilience in Stressful Events (RISE) - John Hopkins Hospital (JHH)
At Johns Hopkins Hospital (JHH), patient safety leaders identified a lack of consistent,
timely support from the institution to their healthcare workers who were experiencing a second
victim phenomenon. After a significant adverse patient-related event in their pediatric unit in
2001 (event details are not available), the entire pediatric departmental staff were negatively
affected suffering emotional distress, however, no resources were available to support them
(Edrees et al., 2016). The need for a peer support program was identified and in 2010 the
development of the RISE (Resilience in Stressful Events) peer support program began with a
survey administered at the JHH Safety Summit after a presentation on second victims. The
survey aimed to better identify the types of support needed by healthcare workers; two-thirds of
respondents reported emotional distress after an adverse event and more than half of the
respondents reported they had reached out for support from a peer or colleague (Edrees et al.,
2016). JHH utilized a multi-disciplinary development team, including patient safety leaders, risk
management administrators, and departmental staff to lead strategic planning, develop a
leadership plan, and determine training and resources needed to implement a successful program.
The RISE program was developed in four distinct phases: (a) development of the mission of the
program; (b) procedural process of responding to identified second victims; (c) recruiting and
SECOND VICTIM PROGRAMS 12

training peer responders; (d) a pilot launch for testing with goals of hospital-wide
implementation. RISE team objectives were identified as increasing awareness of the second
victim phenomenon among workers in high risk environments, provide multi-disciplinary peer
support via one-on-one or group environments, arm managers and employees with effective
coping strategies, and develop a non-punitive environment with policies and culture shifts.
Additionally, tools for continual assessment of the RISE program’s necessity and overall
effectiveness were developed through peer responder self-evaluation. The self-evaluations
identified that support of the program from organizational stakeholders was paramount to
program development, implementation, and success (Edrees et al., 2016). However, according to
Edrees et al. (2016) inherent limitations to implementation of the RISE program included limited
institutional awareness to which the extent and importance of the second-victim problem existed,
and the need to evaluate the outcome encounters coupled with the potential legal ramifications
for staff members. Financial limitations to obtaining further data collection and monitoring were
acknowledged as an additional barrier.
In a subsequent cost-benefit analysis of the RISE program, which evaluated the nursing
staff at a 1,000-bed private hospital in the United States who used the program between the years
2015 and 2016, the cost of running the program, nurse turnover, and nursing time off were
modeled. The results yielded a net monetary benefit savings of $22,576.05 per nurse who
initiated a RISE call. The budget impact analysis additionally found that a hospital could save
approximately $1.81 million dollars, per year, as a direct result of implementation and utilization
of the RISE program (Moran et al., 2017). These savings were determined to be 99.9%
consistent based on a probabilistic sensitivity analysis, offering encouraging results for hospitals
to implement an institution-wide support program.
SECOND VICTIM PROGRAMS 13

Mitigating Impact in Second Victims (MISE) - Online Support Program
Mira et al. (2017) identified the need of an initiative focusing specifically on raising
awareness and prevention of the second victim phenomenon. The completely web-based
Mitigating Impact in Second Victims (MISE) program, developed by Mira et al. (2017) was
designed and implemented based on patient safety data. The goal was to facilitate second victim
awareness information and educate healthcare professionals on common behavior and the
emotional reactions most often exhibited after involvement in an adverse event. The MISE
program was dynamically structured with two complementary components: an informative
component and a demonstrative component. The informative package provided information to
the user on the most basic patient safety concepts such as adverse events, avoidability, and
causality. Additionally, the concepts of what a first, second, and third victim entail were also
provided. The demonstrative portion provided an in-depth description of the impact adverse
events can potentially have on healthcare professionals, how a professional can become a second
victim, and coping mechanisms. This portion was delivered in a clinical scenario video for
relatability (Mira et al., 2017).
The MISE program was put through extensive self-assessment and external evaluation by
safety professionals, hospital and administrative healthcare professionals, and independent
national patient safety experts (Mira et al., 2017). The following characteristics of the program
were highlighted: usability, accessibility, confidentiality-privacy, transparency, credibility,
editorial policy, elements related to the Web user, attribution of contents, updating of
information, and provision of electronic services (Mira et al., 2017).
Distribution of the program consisted of twelve, thirty-minute sessions totaling an
average of five hours of prevention education. Participants who completed the online training
SECOND VICTIM PROGRAMS 14

reported increasing their knowledge in the following areas: patient safety and associated
terminology, adverse event impact on healthcare professionals, recommended support
interventions, and what to do following an adverse event (Mira et al., 2017). It was also noted
that a significant difference existed in the pre and posttest measurements of the knowledge test of
information, basic patient safety concepts, prevalence and nature of adverse events (SD 1.6;
P<0.001) as well as what to do after an adverse event or error (SD 1.0; P<0.001) (Mira et al.,
2017). The authors concluded the MISE program is not only cost effective to implement but is
also effective in providing awareness and prevention information to high risk healthcare
professionals that is both comprehensive and easily accessible.

Alternative Institutional Support Programs
Code Lavender - University of California Health, San Diego (UCSD)
Code Lavender, an emotional support tool, was designed to mitigate the second victim
phenomenon by increasing the feeling of provider support and positive work relationships
(Davidson, Graham, Montross-Thomas, Norcross, & Giovanna, 2017). A pilot study of
intentional acts of kindness at the University of California Health, San Diego (UCSD), aimed to
shift unit-based culture toward encouraging early identification of stressful workplace events and
support of colleagues through experiencing critical events that could result in a second victim
experience (Davidson et al., 2017). The Code Lavender intervention consisted of a lavender-
colored mesh drawstring bag containing: a lavender aromatherapy vial which could be privately
smelled by the staff member (to assist with sense of calmness), a piece of chocolate (to
encourage a positive sensory experience), and a small card with encouraging words chosen by
SECOND VICTIM PROGRAMS 15

staff members (Davidson et al., 2017). A referral card for additional resources through an
Employee Assistance Program (EAP) was also provided to the healthcare professional.
The success of the code lavender packets was determined by utilizing pre-intervention
professional quality of life (ProQol) surveys and directly compared with the post intervention
ProQol surveys of staff members and physicians. The survey results showed no statistically
significant difference in the pre and post ProQol scores, specifically in the areas of compassion
satisfaction, burnout, secondary traumatic stress, and job satisfaction. Additional feedback,
utilizing open ended questions, however showed an overall positive perception of Code
Lavender. The ProQol report also revealed the low cost associated with implementation of the
code lavender packets, enabling possible incorporation into a larger, more comprehensive
support program with the goal of shifting workplace culture to more promptly recognize those
suffering from heightened workplace stress and progressing toward becoming second victims.
Employee Assistance Program (EAP)
Healthcare professionals lack a robust awareness of the second victim phenomenon and
of the available supportive resources needed to prevent functional impairment, improve quality
of care, and rebuild patient relationships (Seyes et al., 2013). Immediately following an adverse
event, the healthcare provider should be aware of their organizational contact support person
(Scott et al., 2010). During the initial disorientation period commonly following the second
victim experience, unit leadership involvement is imperative in coordinating care to both the first
and second victims. Employee Assistance programs (EAP) are an additional resource typically
available through the human resources departments in most healthcare institutions nationwide
and provide hospital-based tools and services to all its employees who may be experiencing any
form of stress or grief (Edrees et al., 2017). These types of programs are not specific to treating
SECOND VICTIM PROGRAMS 16

second victims, as they are a more generalized support process. In a study by Edrees et al.
(2017), patient safety leaders believed that the EAPs were not meeting the needs of their second
victims and lacked timeliness, availability, convenience and appropriately trained staff.
The University of California, San Diego (UCSD) hospital Faculty and Staff Assistance
Program (FSAP) provides second victim specific employees with one-on-one information,
support, educational workshops, support groups, and counseling (UCSD, 2018). UCSD’s
assistance program works to provide seven educational classes which include: Building Respect
and Dignity, Hard Times for Busy Professionals, Strategies for Stress Management, Humor for
the Health of It, Resiliency Toolbox, Supervisor’s Toolkit, and Workplace Bullying (UCSD,
2018). Classes such as these, not only help to rebuild confidence, but also lend support to second
victims during initial and persistent effects of adverse events. Organized support groups within
the institution additionally provide a social community to help the second victim overcome
withdrawal and blame amongst peers.

SECOND VICTIM PROGRAMS 17

Chapter 3
Methods
This literature review employed a two-step search strategy. The first step was a search of
the online databases PubMed and Embase using the search terms: second victim, second victim
hospital program, second victim support, patient safety program, critical incident, adverse event,
medical error, employee assistance program. The second step included a manual search of
reference lists from all relevant sources identified in the first step. The included journal articles
were reviewed, and their citations were further evaluated for additional discovery of relevant
literature. A modified PRISMA method for reporting flowchart is displayed in Appendix A.
Inclusion criteria consisted of the following five elements: (a) journal articles published in the
English language with full text, (b) identified a need for second victim programs in a healthcare
setting, (c) identified processes for implementing a second victim program in the healthcare
setting, (d) reviewed second victim peer support services, and (e) identified the design of a
second victim program. Literature investigating second victim programs outside of the healthcare
setting, and duplicate articles were excluded from the literature review.
The process of article selection is displayed in Appendix A. After compiling the article
selections, the Joanna Briggs Institute (JBI) (JBI, 2018) critical appraisal tool was used for
quality appraisal of each article. The JBI critical appraisal tool provides specific checklists-based
research methods to assess an article’s methodological quality, bias, conduct and design (JBI,
2018). The key characteristics of the selected articles are displayed in the literature matrix
(Appendix B).

SECOND VICTIM PROGRAMS 18

Gap Analysis
A gap analysis (Appendix C) was conducted which identified a deficiency in the number
of comprehensive second victim support programs implemented in healthcare settings. After
completion of an extensive literature review, eight healthcare programs were identified meeting
inclusion criteria, further validating the results of the gap analysis. The gap analysis highlighted
the insufficient number of second victim programs and the need to implement a better second
victim support infrastructure within the healthcare setting.

SECOND VICTIM PROGRAMS 19

Chapter 4
Results
This literature review identified commonalities and themes amongst the published second
victim support programs which led to the identification of the most essential elements that make
a hospital based second victim program successful. These identified elements are recommended
as best practice for institutionalizing a comprehensive second victim support program:
1. Implementing an institutional wide survey to determine the prevalence of second victim
phenomenon and the need for implementing a support program.
2. The establishment of multidisciplinary committees utilizing colleagues, unit managers,
supervisors, administration, etc. for creation of a comprehensive program and to gain
institutional wide buy-in.
3. Institution wide promotion of second victim awareness through informal communication
efforts such as: emails, posters, and unit meeting. Prevention of second victim
phenomenon through educational online modules for healthcare professionals
incorporated into annual healthcare training. Informal and formalized types of
educational platforms both increase awareness and prevention to foster increases in
institution wide visibility of second victim phenomenon and availability of support
services.
4. The integration of peer support volunteers at the unit/department level. This includes
basic training with the aim of many available colleagues for immediate peer support.
5. Instituting advanced peer support training, utilizing validated training tools, for selected
individuals such as unit leaders, supervisors, and managers who are available to provide a
higher level of crisis intervention.
SECOND VICTIM PROGRAMS 20

6. Increased access to peer supporters who are available 24 hours a day, 7 days a week, with
an emphasis on maintaining encounter confidentiality.
7. Multilevel or tiered support structure to include immediate peer support, intermediate
level support availability and Professional long-term support if desired or needed.
8. Integration of the validated Second Victim Experience and Support Tool (SVEST)
utilizing encounter forms for continued analysis and evaluation of encounters and
effectiveness of interventions and support.

The eight identified essential interventions are recommended as best practice for the
implementation of a comprehensive second victim support program in any healthcare institution.
The RISE program implemented at John Hopkins Hospital encompassed all eight identified
essential elements for institutionalizing a comprehensive second victim support program.
Additionally, it is our goal that these recommendations can aid in decreasing the time burden of
executing a comprehensive support program from the ground up, resulting in a faster rollout and
available resources for healthcare providers.

SECOND VICTIM PROGRAMS 21

Chapter 5
Discussion
After an adverse event, healthcare providers can suffer from emotional distress, affecting
their ability to care for their patients and effectively cope with the impact (Seys et al., 2013).
Therefore, it is important that institutions have support programs in place for immediate and
long-term intervention to effectively mitigate the effects of the second victim phenomenon.
Promotion of a work environment that emphasizes open dialogue, transparency in actions,
quality in patient care delivered, and safety can additionally help to improve institutional culture
and healthcare providers satisfaction (Seys et al., 2013).
This research aimed to provide a comprehensive overview of essential elements needed
to support second victims through the evaluation of existing second victim programs. In doing
so, six second victim specific programs and two alternative institutional support programs were
evaluated (Table 3). The following eight elements have been highlighted by the authors as
providing the most comprehensive support to meet the unique needs of a second victim.
Strategies for continued prevention and long term interventions include: (a) a survey to
determine second victim prevalence, (b) establishing multi-disciplinary committees, (c)
promoting awareness and prevention of second victim phenomenon, (d) utilizing peer support
groups, (e) training peer supporters, (f) access to peer support, (g) multi-level support systems,
and (h) evaluation and analysis of interventions.
After evaluating the second victim programs and alternative institutional support
programs, two prominent themes emerged: (a) survey results indicating a high prevalence of
second victims within a hospital organization and (b) integration of peer supporters at the
unit/departmental level. By identifying the prevalence of healthcare workers becoming second
SECOND VICTIM PROGRAMS 22

victims, a hospital organization was also able to identify that most long-term effects of second
victim phenomenon could be mitigated through the initial implementation of a peer support
system.
Another important finding from the literature review is that Employee Assistant
Programs (EAPs) fail to provide trained support, multidisciplinary committees, or prevention
awareness to second victims. Without completing a second victim prevalence survey, hospital
EAPs lack the necessary data to implement adequate support interventions for second victims.
Employee Assistance Programs lack a proactive approach to capturing and preventing the second
victim phenomenon which proves EAPs are not sufficient in supporting the needs of second
victims following an adverse event or medical error.

Table 3: Second Victim Programs and Alternatives Institutional Support Programs
Critical Elements of Second Victim Programs
Program
Prevalence
Survey
Multi-
Discipline
Committee
Prevention
Awareness
and
Education
Peer
Supporters
Trained
Peer
Supporters
24/7
Availability
to Peer
Support
Multi-
Level
Support
System
Evaluation
and
Analysis
PST ✔

✔

MITSS ✔

✔

✔
forYOU
Team
✔ ✔

✔ ✔ ✔ ✔

YOUmatter ✔ ✔ ✔ ✔ ✔

✔
RISE ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔
MISE
✔

✔
Code
Lavender
✔

✔ ✔

EAPs
✔

▪ The ( ✓) denotes included in the program
▪ Blank box denotes not included in the program
SECOND VICTIM PROGRAMS 23

Limitations
This review of the literature has few limitations. The first is the acknowledgement of the
limited number of published second victim support programs. Additionally, almost all the
programs analyzed are variations of each other, evolving from one another. Therefore, some
program replication is identified, potentially inflating the resulting effectiveness of any
intervention. Third, creating a second victim support process infrastructure at a given healthcare
facility, can take upwards of four years without a formal process to emulate, thus creating a
barrier for healthcare organizations to timely and efficiently implement structured support
programs (Scott et al, 2010). Lastly, there are second victim programs that are being
implemented in the greater Los Angeles area (a large metropolitan city in the United States),
however these programs were not included in this review because the official published data
could not be obtained. Future reviews should strive to include these programs once that data is
published or made publicly available.
At this time, no literature has been identified opposing the usefulness of second victim
programs. Although creating and maintaining support programs with appropriate resources and
personnel can be costly, it is often less costly than the alternative of an employee taking time off
or losing an employee due to ineffective coping (Moran et al, 2017). The cost-benefit analysis of
the RISE program only evaluated the nursing profession and no further data has been published
at this time regarding cost-benefit ratio of other programs.
Conclusion
Second victim support programs are vital for healthcare providers as a means for
emotional resolution and mutual support, however the data on second victim support programs is
limited to descriptions of specific hospitals that have developed and implemented programs
(Edrees et al., 2017). The common themes identified among the reviewed programs are
SECOND VICTIM PROGRAMS 24

increased awareness and improved outcomes of the second victim, however, there remains a gap
in identifying the most beneficial and effective features of the specified programs. In order to
extrapolate the essential aspects of second victim support programs and put forth best practice
recommendations, that can be easily adapted to any healthcare setting, continued evaluation of
second victims’ needs are necessary including the structure of institutional support programs and
the associated interventions (Dukhanin et al., 2018).

SECOND VICTIM PROGRAMS 25

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healthcare professionals as second victim. International Nursing Review, 64, 242-262.
https://doi.org/10.1111/inr.12317
Davidson, J. E., Graham, P., Montross-Thomas, L., Norcross, W., & Zerbi, G. (2017). Code
lavender: cultivating international acts of kindness in response to stressful work, 13(3),
181–185. https://doi.org/10.1016/j.explore.2017.02.005
Dukhanin, V., Edrees, H. H., Connors, C. A., Kang, E., Norvell, M., & Wu, A. W. (2018).
Journal of Pediatric Nursing Case: A second victim support program in pediatrics:
Successes and challenges to implementation. Journal of Pediatric Nursing,41, 54–59.
https://doi.org/10.1016/j.pedn.2018.01.011
Edrees, H., Connors, C., Paine, L., Norvell, M., Taylor, H., & Wu, A. W. (2016). Implementing
the RISE second victim support program at the Johns Hopkins Hospital: a case study.
BMJ Open, 1–12. https://doi.org/10.1136/bmjopen-2016-011708
Edrees, H., Morlock, L., Wu, A. W. (2017). Do Hospitals support Second Victims? Collective
insights from Patient safety leaders in Maryland. The Joint Commission Journal on
Quality and Patient Safety, 43, 471-483. https://doi.org/10.1016/j.jcjq.2017.01.008
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http://joannabriggs.org/research/critical-appraisal-tools.html
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Tools. http://mitss.org/who-we-serve/healthcare-organizations/
Merandi, J., Liao, N., Lewe, D., Morvay, S., Stewart, B., Catt, C., & Scott, S. D. (2017).
Deployment of a second victim peer support program: A replication study. Wolters
Kluwer Health, 2(4), 1–8. https://doi.org/10.1097/pq9.0000000000000031
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Mira, J., Carrillo, I., Guilabert, M., Lorenzo, S., Perez-Perez, P., Silvestre, C., & Ferrus, L.
(2017). The second victim phenomenon after a clinical error: The design and evaluation
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W.V. (2017). Cost-benefit analysis of a support program for nursing staff. Journal of
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Pratt, S., Jachna, B. (2015). Care of the clinician after an adverse event. International Journal of
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Quality and Patient Safety, 38(5), 235-240. https://doi.org/10.1016/s1553-
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Schroder, K., Edrees, H., Christensen, R., Jorgensen, J., Lamont, R., Hvidt, N. (2018). Second
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need? International Journal for Quality in Health Care, 1-7.
https://doi.org/10.1093/intqhc/mzy219
SECOND VICTIM PROGRAMS 27

Scott, S. D., Hirschinger, L. E., Cox, K. R., McCoig, M., Hahn-Cover, K., Epperly, K. M., …
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https://doi.org/10.1016/s1553-7250(10)36038-7
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(FSAP). Retrieved from: https://blink.ucsd.edu/sponsor/hr/divisions-units/fsap.html
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and Gallagher, T. (2015). Risk managers descriptions of programs to support second
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Wu, A., (2000). Medical error: the second victim. The doctor who makes the mistake needs help
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df

SECOND VICTIM PROGRAMS 28

Appendix A: Modified PRISMA Flowchart

SECOND VICTIM PROGRAMS 29

Appendix B: Literature Matrix
Author(s)
Research
Design/Setting
Findings Recommendations
Chan, S., Khong, P.,
Wang, W.
(2016).
• Systematic
Literature Review
• Healthcare
professionals’
psychological
responses, coping
and support needs
• Physiological responses:
guilt, anxiety, anger,
insufficiency
• Coping strategies: problem-
focused, emotion-focused,
talking
• Support needs: emotional
aid, secure formal support,
safety culture
• Exploring second victim
physiological responses
yielded guilt, anxiety,
anger, insufficiency
Davidson, J. E.,
Graham, P.,
Montross-
thomas, L.,
Norcross, W., &
Zerbi, G. (2017).
• Pilot study
• University of
California Health
San Diego

• Code Lavender
Implementation
• Code Lavender description
• 100% staff reported it was
helpful
• 84% staff recommend to
others
• Promoting intentional acts
of kindness in the
workplace through
programs such as code
lavender → low cost and
positively received
• Helping to decrease
workplace stress and shift
the culture
Dukhanin, V.,
Edrees, H. H.,
Connors, C. A.,
Kang, E.,
Norvell, M., &
Wu, A. W.
(2018).
• Case Study
• Mixed-Method

• The mixed-method approach
allowed a comprehensive
evaluation of RISE and
provided some evidence for
its effectiveness in
supporting pediatric health
care workers
• Findings suggest an
important role of
organizational culture in
second victim support
program implementation
and evaluation
• Organization culture that
can help enhance second
victim support
• Using validated survey
tools: SVEST, HSOPS
• Program must be flexible,
self-learning and account
for culture (which can be
a limiting factor)
Edrees, H., Connors,
C., Paine, L.,
Norvell, M.,
Taylor, H., &
Wu, A. W.
(2016).
• Describe the
development of
RISE and evaluate
• Mixed-methods
study
• Descriptive
statistics
• Qualitative
analysis and
coding used to
analyze open
ended responses
from
questionnaires and
focus groups
• Baseline staff survey found
that most staff had
experienced an
unanticipated adverse event,
and most would prefer peer
support
• Majority of calls were from
nurses, and very few calls
were related to medical
errors
• Low awareness of the
program was a barrier to
hospital wide expansion, but
over four years, call rates
increased
• Confidentiality must be
ensured for successful
peer support program
• Committed leaders and
involvement of
stakeholders
• Program marketing and
awareness increase
success
SECOND VICTIM PROGRAMS 30

Author(s)
Research
Design/Setting
Findings Recommendations
Edrees, H., Morlock,
L., Wu, A. W.
(2017).
• Qualitative
analysis
• N = 46
• All but one of the
responding hospitals offered
EAP services to their
employees
• No valid measures in place
to assess EAP services
• Participants identified a
need for peer support to
victims and those that
provide the support
• Organizations need to
reevaluate the support
currently provided by
their EAPs
• Consider additional peer
support mechanisms.
• Future research is needed
to evaluate the
effectiveness of these
programs

Merandi, J., Liao, N.,
Lewe, D.,
Morvay, S.,
Stewart, B., Catt,
C., & Scott, S. D.
(2017).
• Deployed program
for 6 months
• Pediatric
academic
institution with a
robust voluntary
adverse event
reporting system
and a strong
culture of patient
safety
• MUHC’s model proved to
be an efficient and practical
approach to NCH team
design and deployment,
making it transferable to
other health care entities
• Demonstrated second
victims occur across the
healthcare continuum with
an increased prevalence in
areas of high patient acuity
and death
• Peer support is preferred
by medical professionals
• Ongoing evaluations of
effectiveness
• Continue recruitment of
new members
• ED and ICUs found to
have the most need, thus
might need more access
Mira, J., Carrillo, I.,
Guilabert, M.,
Lorenzo, S.,
Perez-Perez, P.,
Silvestre, C., &
Ferrus, L. (2017).
• Qualitative
research based on
literature review
• Pilot study
• Designed online
educational and
preventative
program for
hospital and
primary care
professionals
• MISE program creates an
intervention that is
preventative in relation to
second victims
• Strengths are easily
accessible tool, increasing
user’s knowledge base
• Low cost to implement

• Continues prevention and
educational initiatives
• Designed to be used as
assistive or adjunct
interventions, as MISE is
NOT recovery program
• Future research on MISE
impact and effectiveness

Moran, D., Wu,
A.W., Connors,
C., Chappidi,
M.R., Sreedhara,
S.K., Selter, J.H.,
and Padula,
W.V. (2017).
• Cost benefit
analysis
• Evaluate the
impact of the
RISE program by
conducting an
economic
evaluation of its
cost benefit
• The RISE program resulted
in a net monetary savings of
$22,576.05 per nurse who
initiated a RISE call, and
hospitals savings of 1.81
million each year because of
the program
• Stressful events can lead
to burnout and high
turnover rates, which
negatively impact patient
care
• Having a peer-support
program for medical
providers may provide
hospitals with a
substantial return on
investment and this,
continue good value for
the hospital
SECOND VICTIM PROGRAMS 31

Author(s)
Research
Design/Setting
Findings Recommendations
Seys, D., Scott, S.,
Wu, A., Gerven,
E. Van,
Vleugels, A.,
Euwema, M., …
Vanhaecht, K.
(2013).
• Literature Review

• Second victim support is
needed to care for healthcare
workers and improve the
quality of care
• Support: provided at
individual and
organizational level
• Programs need to provide
support immediately, and
intermediate and long-term
basis

• Support for the second
victim must be
incorporated in the
organizational and
individual level
• Support needs to occur
immediately after the
event
Schroder, K., Edrees,
H., Christensen,
R., Jorgensen, J.,
Lamont, R.,
Hvidt, N. (2018).
• Descriptive
Statistics
• Quantitative
Research
• Questionnaire
• 1,237 participants
• High response for social
community after adverse
event
• Low response from
superiors
• Level of social support
from colleagues and
managers following
adverse event
• Promote a “Just Culture”
with less blaming and
shaming

Scott, S. D.,
Hirschinger, L.
E., Cox, K. R.,
McCoig, M.,
Hahn-Cover, K.,
Epperly, K. M.,
… Hall, L. W.
(2010).
• Qualitative
Research
• Survey
• Interviews
• Identifying the problem
• Developing Second Victim
Response System
Requirements
• Framework for caring
• Support initiatives for
second victims are a
moral obligation of
healthcare institutions
• Institutional commitment
is necessary
• Incorporation of already
established support
systems

Scott, S. D., &
Mccoig, M. M.
(2016).
• Qualitative
Research
• Focused Group
• Unanticipated
clinical events
• Second-victim stages of
recovery
• Predictable pathway for
recovery
• Clinician support
• Social support initiatives
would be established
within the healthcare
setting and widely
dispersed
• Create a culture of
proactive support services
for clinicians
• Intentional design and
delivered support
• Comprehensive response
plan is imperative for
protecting clinicians

SECOND VICTIM PROGRAMS 32

Author(s)
Research
Design/Setting
Findings Recommendations
University of
California, San
Diego (UCSD).
(2018).
• Educational
website
• Implemented
hospital setting
• Support groups
• Educational workshops
• One-one counseling
• Organization offering
support and counseling
• Organization offering
educational and
supportive classes

VanPelt, F. (2008). • Opinion
• Description of
adverse event
where open
communication
and apology
catalyzed the
development and
implementation of
a structured peer
support service

• Peer Support Service
eliminate stigmas associated
with formal support services
• Sustainable improvements
depend on the integration of
a supportive and
compassionate work
environment with systems-
based thinking
• Physician culture can
remain resistant to PST
• Continued education for
providers and peer
supporters
• Safe institutional
environment is necessary
• Long term needs for
comprehensive emotional
support response
White, A.A., Brock,
D.M., McCotter,
P.I., Hofeldt, R.,
Edrees, A.H.,
Wu, A.W.,
Shannon, S., and
Gallagher, T.
(2015).
• Case report
• Quantitative data
• Survey 635 US
members of the
American Society
for Healthcare
Risk Management
(ASHRM)
• 73.6% of respondents
reported their organization
had a program to provide
emotional support to
healthcare workers after
adverse events - but vary in
structure and staffing and
many lacking important
elements

• Need for institutions to
widely adopt
improvements such as
referrals by watchful
department leaders and
reaching out to support all
clinicians after adverse
events, regardless of
whether support appears
necessary
• Healthcare organizations
should establish systems
to quantify, track, and
promote provider support
service use
• Asses structure and
utilization of local support
programs
• Assess efficacy of local
support programs
• Raise awareness
• Set a plan to close gaps
with recommended
services

SECOND VICTIM PROGRAMS 33

Appendix C: Gap Analysis
CLASSIFY THE
PROBLEM
DEFINE BEST PRACTICE MEASURE GOALS
Problem Identification: After
an extensive literature review,
only seven support programs
were identified; Within these
seven programs, support
measures vary widely
Literature Review: Identify and
assess support characteristics
and frameworks within
published hospital based second
victim support programs.
Process Improvement: Improve
second victim programs through
identifying published support
programs and assessing essential
characteristics
Participants: First, Second,
and Third Victims
Guidelines: Perform extensive
literature review for best practice
support recommendations
Evaluate Process and Outcome:
Extensive literature review of
existing literature on second victim
programs
Feasibility of implementing a
support program: Many
institutional steps to overcome in
order to implement a support
program, push back of culture
change within institutions, time
consuming

Benefits: Creation of a no-blame
culture, feeling of openness
amongst peers, informed
providers, net cost savings for
hospitals with implemented
programs
Risks: Lack of provider
participation, decline in
utilization if implemented
without follow-up
Adapt or Delete: Adapt for future
creation of a standardized second
victim program

Abstract (if available)

Abstract For healthcare professionals, witnessing or experiencing adverse patient outcomes is difficult. Unanticipated patient harm or a medical error, resulting in patient injury, can have particularly damaging effects to a healthcare provider’s well-being. This is referred to as the second victim phenomenon and these providers can experience significant emotional distress impacting all areas of their life. It is estimated that nearly half of all healthcare workers experience some form of an adverse event, in which they become a second victim, at least once in their career, therefore institutional based support is paramount. While hospitals may be implementing programs to support second victims, these programs may be incomplete and ineffective in providing support. The focus of this review is to identify essential elements of hospital-based second victim support programs that are most representative of a comprehensive program. An extensive literature search was electronically conducted, and a common theme identified throughout the literature emphasized the need for hospital-based support programs utilizing peer supporters. The most comprehensive program identified was the RISE (Resilience in Stressful Events) program at John Hopkins Medical Center which institutionalized a short operational timeline, 24/7 peer supporters, and tiered levels of professional support interventions. Second victim support programs are essential to mitigating the potential devastating emotional distress a healthcare worker can experience after an adverse event. It has become increasingly important that hospitals offer comprehensive, timely support interventions to meet the needs of their employees who may become second victims.

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Asset Metadata

Creator Yeung, Monica Sarah (author)

Core Title Second victim programs within the hospital setting: an extensive literature review with practice recommendations

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Publication Date 05/06/2020

Defense Date 05/05/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag adverse event,critical incident,employee assistance program,medical error,OAI-PMH Harvest,patient safety program,second victim,second victim hospital program,second victim support

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Gold, Michele E. (committee chair), Bamgbose, Elizabeth (committee member), McCall, Erica (committee member)

Creator Email monicastoch@gmail.com,yeungmon@usc.edu

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Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA