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psnet.ahrq.gov/node/73865/psn-pdf
September 22, 2021 - safety-incident
An online survey of nursing students in Belgium found that about one in three students were involved … Medical and nursing curriculum should include opportunities for competency development to support
peers involved … second-victims-among-baccalaureate-nursing-students-aftermath-patient-safety-incident
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
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psnet.ahrq.gov/issue/patient-harm-and-institutional-avoidability-out-hours-discharge-intensive-care-analysis-using
February 10, 2021 - Based on qualitative interviews with patients, family members, and staff involved in the ICU discharge … Out-of-hours discharges often occurred prematurely, without adequate handovers , and involved patients
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psnet.ahrq.gov/issue/association-open-communication-and-emotional-and-behavioural-impact-medical-error-patients
February 16, 2022 - ago, 51% reported at least one emotional impact, 57% reported avoiding the doctor(s) or facility(s) involved … that open communication can reduce persistent emotional impacts and avoidance of doctors/facilities involved
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psnet.ahrq.gov/issue/patient-safety-incidents-describing-patient-falls-critical-care-north-west-england-between
August 04, 2021 - incidents in critical care units in England between 2009 and 2017 and found that a small proportion (2%) involved … Common factors involved in fall incidents included patients attempting tasks without assistance, patient
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psnet.ahrq.gov/issue/second-victim-syndrome-intensive-care-unit-healthcare-workers-systematic-review-and-meta
March 24, 2019 - Healthcare workers who are involved in patient safety incidents and experience adverse psychological … recover at all, underscoring the importance of organizational support programs for healthcare workers involved
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psnet.ahrq.gov/issue/healing-our-own-randomized-trial-assess-benefits-peer-support
May 19, 2021 - Peer support programs are increasingly used to support clinicians involved in adverse events. … This evaluation found that a structured peer support program for providers involved in obstetric adverse
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psnet.ahrq.gov/issue/analysis-iatrogenic-and-hospital-medication-errors-reported-united-states-poison-centers
November 28, 2018 - Antibiotics, pain medicines, and sedatives/hypnotics were the most common medication types involved in … these errors, and the most common error types involved the wrong medication, incorrect dose and incorrect
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psnet.ahrq.gov/node/74267/psn-pdf
January 19, 2022 - support-opportunities-second-victims-lessons-learned-qualitative-study-top-20-
us-news-and
Many hospitals are implementing programs to support clinicians involved … evaluation-second-victim-peer-support-program-perceptions-second-victim-experiences-and
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events … https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
https
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psnet.ahrq.gov/node/60306/psn-pdf
May 06, 2020 - The most common medication errors involved diphenhydramine and dextromethorphan. … Almost half of medication errors (45.8%) involved children between the ages of 2 and 5 years old and … involved administration by either a parent (45%) or alternative caregiver (28.8%).
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psnet.ahrq.gov/issue/second-victim-experiences-health-care-learners-and-influence-training-environment-postevent
January 31, 2024 - Clinicians involved in medical mistakes benefit from assistance to psychologically recover from the experience … September 21, 2022
Peer support and second victim programs for anesthesia professionals involved
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psnet.ahrq.gov/issue/medication-adverse-events-ambulatory-setting-mixed-methods-analysis
October 21, 2020 - Anticoagulants , antibiotics, hypoglycemics, and opioids were the most commonly involved medication classes … December 2, 2020
WebM&M Cases
Multiple Levels Involved
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psnet.ahrq.gov/issue/use-second-victim-experience-and-support-tool-svest-assess-impact-departmental-peer-support
December 23, 2020 - Providers involved in patient safety incidents can experience adverse psychological and physiological … March 13, 2024
Peer support and second victim programs for anesthesia professionals involved
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psnet.ahrq.gov/issue/making-infusion-error-second-victims-infusion-therapy-related-medication-errors
June 27, 2018 - Providers involved in medical errors may experience emotional distress, referred to as the second victim … The authors of this survey study describe nursing graduates' experiences after being involved in medication
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psnet.ahrq.gov/issue/emotional-impact-medical-errors-practicing-physicians-united-states-and-canada
January 23, 2008 - This survey sought to evaluate the effects of medical errors on the emotional health of the physician involved … The majority of more than 3000 physicians surveyed had been involved with a serious medical error resulting
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psnet.ahrq.gov/issue/duration-second-victim-symptoms-aftermath-patient-safety-incident-and-association-level
June 09, 2021 - Clinicians may experience distress after being involved in adverse events. … The authors call for organizations to provide support for clinicians involved in adverse events.
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psnet.ahrq.gov/issue/content-analysis-patient-safety-incident-reports-older-adult-patient-transfers-handovers-and
December 14, 2022 - transitions in geriatrics, cardiology, orthopedics and stroke to identify the types of transitions involved … Half of all incident reports involved interunit/department/team transfers and the majority (69%) of incidents
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psnet.ahrq.gov/node/42068/psn-pdf
April 09, 2013 - themselves as having increased compassion, humility, and tolerance for
uncertainty as a result of being involved … This
study illustrates the second victim phenomenon that affects many clinicians who are involved in … resident-uncertainty-clinical-decision-making-and-impact-patient-care-qualitative-study
https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event … https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event
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psnet.ahrq.gov/node/48176/psn-pdf
July 31, 2019 - duration-second-victim-symptoms-aftermath-patient-safety-incident-and-
association-level
Clinicians may experience distress after being involved … The authors call for organizations to provide support for
clinicians involved in adverse events. … duration-second-victim-symptoms-aftermath-patient-safety-incident-and-association-level
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
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psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
May 11, 2014 - This operating room (OR) case also involved a look-alike packaging issue ( Figure ). … Heparin was involved in 143 (3.9%); however, it was second among the drugs most frequently associated … (Note: The vials pictured were not involved in the presented case.)
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psnet.ahrq.gov/issue/promoting-psychological-well-being-healthcare-providers-facing-burden-adverse-events
February 15, 2023 - Clinicians involved in unexpected patient outcomes can experience negative emotions and frequently need … September 19, 2016
Supporting involved health care professionals (second victims) following