52 Questions
What is a major concern regarding the use of the term 'second victim'?
It minimizes the harm experienced by the patient
According to a nationwide survey, what percentage of pharmacists reported being involved in a medication error?
95.5%
How do healthcare organizations often react to an error involving a health professional?
They are often in conflict about how to act
What is a common reaction of patients who experience an error?
They confront the healthcare professional
What is a concern about the term 'second victim' in relation to healthcare professionals?
It suggests that the error was unavoidable
What is a key issue surrounding the term 'second victim' in healthcare?
It is a contested term
What percentage of respondents felt that healthcare organizations offered inadequate support for coping with stress?
90
What is the reason many health professionals harmed by involvement in a medical error are never involved in disclosure?
All of the above
What is the result of full disclosure on patients considering filing a lawsuit?
They are less likely to file a lawsuit
What is involved in the full disclosure process?
Disclosure of the error, an explanation, steps to prevent recurrences, acknowledgement of responsibility, and an apology
What is the benefit of formal training in error disclosure?
It improves providers' comfort with the process
What is the reason clinicians may be hesitant to disclose errors?
All of the above
What is the result of non-disclosure in the example scenario?
The patient is unaware of the error
What is the important consideration in full disclosure regarding malpractice lawsuits?
The clinician's error disclosure may be admissible in court
How many states in the U.S. have specific laws regarding error disclosure?
Eight
What is the importance of handling the error disclosure process thoughtfully and sensitively?
It prevents alienating patients and families
What is the primary distinction between human error and negligence in the context of healthcare?
Human error involves a failure to exercise the skill, care, and learning expected of a healthcare provider.
According to the Just Culture approach, how should management respond to an individual who exhibits at-risk behavior?
Coach the individual and examine the system for contributing factors.
What is the primary goal of a blame-free safety culture in healthcare?
To promote disclosure and reporting of errors to learn from them.
What is the likely outcome of a blame culture in healthcare?
Discouragement of disclosure and reporting of errors.
What is the impact of medical errors on healthcare providers, according to research?
A three-fold increase in depression and burnout.
What is a potential predictor of the emotional impact of a medical error on a healthcare provider?
The level of personal responsibility felt for the error.
What is the primary distinction between a blame-free culture and a just culture in healthcare?
A blame-free culture focuses on system improvement, while a just culture focuses on individual accountability.
What is the impact of a medical error on a healthcare provider's quality of life, according to research?
A decrease in overall quality of life.
According to the Just Culture approach, what is the appropriate response to reckless behavior in healthcare?
Punish the individual to deter similar behavior in the future.
What is the primary goal of a just culture in healthcare?
To balance individual accountability with system improvement and patient safety.
What warning is found on the top of the vecuronium medication vial?
WARNING: PARALYZING AGENT
What was the consequence of RaDonda Vaught's error?
The patient, Charlene Murphey, died
Why did RaDonda Vaught override the medication cabinet safety features?
To get a bag of fluids for a patient quickly
What was the outcome of the medical hearing for RaDonda Vaught?
Her license was suspended
What was the consequence of Eric Cropp's error?
The patient, Emily Jerry, died
What was the reason for the delay in preparing the chemotherapy solution for Emily Jerry?
The pharmacy system was down for maintenance
What assumption did Eric Cropp make during the check of the chemotherapy solution?
The technician had used the 0.9% sodium chloride solution
What was the consequence of Eric Cropp's error for the pharmacy technician?
The technician lost their job
What was the outcome of the Ohio Board of Pharmacy's investigation into Eric Cropp's error?
Eric Cropp's license was revoked
What was the criminal charge brought against Eric Cropp?
All of the above
What was the sentence given to Eric Cropp for involuntary manslaughter?
6 months imprisonment, 6 months of home confinement, 3 years of probation, and a $5,000 fine
What is a major obstacle to error disclosure in healthcare?
Lack of training in error disclosure
What is a benefit of shifting to a just culture in healthcare?
Supporting error disclosure and learning from errors
What are the negative effects of medical errors on healthcare professionals?
Varying negative effects based on the circumstances of the error
What is a key point about medical errors in healthcare?
They are an unavoidable part of health care
What do patients want from healthcare professionals after an error occurs?
A full disclosure and an explanation
What is the primary goal of 'apology laws' in the context of medical malpractice?
To protect healthcare providers from malpractice lawsuits
What is the primary benefit of Morbidity and Mortality (M&M) conferences?
To focus on education and quality improvement in patient care
What is the main purpose of 'confessor' programs in institutions?
To provide formal support to clinicians involved in medical errors
Why did RaDonda Vaught accidentally inject vecuronium into Charlene Murphey?
All of the above
What is the primary reason why formal support programs for clinicians involved in medical errors are lacking?
Due to the informal nature of existing support structures
What is the recommended approach to medical error training in medical education?
All of the above, except a
What is the primary benefit of implementing 'apology laws' in medical malpractice cases?
To reduce medical malpractice lawsuits
What is the main difference between 'admissions of fault' and 'expressions of sympathy' in medical malpractice cases?
Expressions of sympathy are excluded from evidence in malpractice lawsuits, while admissions of fault are not
What is the primary goal of institutional support programs for clinicians involved in medical errors?
To provide emotional support to clinicians
What is the recommended approach to conducting morbidity and mortality reviews?
All of the above, except a
Study Notes
The Concept of Second Victim
- The term "second victim" refers to healthcare professionals who are involved in a medical error
- Critics argue that the term "second victim" minimizes the harm experienced by the patient and suggests that the error was unavoidable
- Healthcare professionals are highly likely to be involved in an error during their career, with 95.5% of pharmacists reporting being involved in a medication error
- Healthcare organizations are often conflicted about how to handle a healthcare professional involved in an error
Patient Reactions to Error
- Patients react and cope in different ways to achieve resolution after an error, including:
- Confronting the healthcare professional(s)
- Filing a lawsuit
- Going to the media with their experience
Key Takeaways
- Medical errors are an unavoidable part of healthcare
- Healthcare professionals also experience negative effects from errors, including depression, burnout, and decreased quality of life
- A "just culture" approach promotes error disclosure, learning from errors, and improving safety within an organization
- Patients want full disclosure from healthcare professionals, but this is often made difficult by legal and training barriers
Differentiating Error from Negligence
- Human error: an individual should have acted differently, resulting in an undesirable outcome
- Negligence: failure to exercise the skill, care, and learning expected of a reasonably prudent healthcare provider
Organizational Safety Culture
- Three types of safety cultures:
- Blame culture: discourages disclosure and reporting, promotes a culture of blame
- Blame-free culture: promotes disclosure and reporting, but lacks transparent investigation of error causes
- Just culture: promotes disclosure and reporting, supports system improvement, and balances accountability with learning from errors
Impact of Medical Errors on Providers
- Medical errors can have a significant emotional impact on healthcare professionals, including:
- Depression
- Burnout
- Decreased quality of life
- Feelings of distress, guilt, and shame
What Healthcare Professionals Should Do When Involved in an Error
- With the patient:
- Do not avoid the patient
- Disclose the error and apologize if appropriate
- Avoid defensive medical practice
- For themselves:
- Recognize that needing support after an error is normal
- Consider supportive discussion with colleagues and family members
- Pursue additional training to better understand and correct mistakes
Error Disclosure
- Full disclosure involves:
- Disclosure of all harmful errors
- Explanation of why the error occurred
- How the error's effects will be minimized
- Steps to prevent recurrences
- Acknowledgement of responsibility and apology
- The benefits of error disclosure include:
- Patients are less likely to consider filing a lawsuit
- Improved patient-provider relationships
- Opportunities for learning and improvement
This quiz explores the concept of 'second victim' in healthcare, referring to the emotional impact of medical errors on healthcare professionals. It discusses the concerns and criticisms surrounding the term, including its potential to minimize patient harm and undermine accountability. Test your understanding of this important topic in patient safety.
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