Statement on Peer Support After Unexpected Outcomes - Treatment of the "Second Victim"

Developed By: Committee on Quality Management and Departmental Administration
Original Approval: October 26, 2022

Executive Summary:

• Anesthesiologists and members of the anesthesia care team provide care for patients at critical moments in their lives, whether during surgery, childbirth, in illnesses requiring intensive care, when suffering from chronic pain, or at the end of life.
• Serious adverse events are inevitable during these episodes of care, and the impact of these events on anesthesiologists and others can be profound.
• These serious adverse events can have a significant impact on anesthesiologists, creating a “second victim,” negatively affecting their physical, mental, and overall well-being.
• Understanding positive coping strategies, considering duty relief, and the implementation of peer support programs may mitigate the impact of these events on anesthesiologists.
• Hospitals, anesthesiology departments, and anesthesiology practices should develop policies in support of physicians and other health care workers when these events occur.

Background:

Whether in an operating room, on a labor floor, in the intensive care unit, in office-based environments, or even in patient homes, the nature of our work as anesthesiologists puts us at risk of experiencing unexpected tragedy. While these events may result from unforeseen adverse outcomes or potentially unavoidable catastrophes during the routine care of critically ill patients, they may also be the result of errors or lapses in judgment by members of the anesthesiology team who are caring for the patient.

As physicians and caregivers, an overarching priority is to address the needs and concerns of patients and their families in the wake of such events. We must not, however, forget that witnessing these tragedies, either suddenly or over long periods of time, may lead to adverse effects on the caregivers themselves. The emotional and psychological impact of these experiences is so great that the term “second victim” was coined to recognize that the impact of these events can be significant and may not always be immediately recognized.

The American Society of Anesthesiologists acknowledges the impact of serious adverse events on clinicians, and strongly recommends that resources and support to help clinicians deal with the impacts of such events be made available to all anesthesiologists, and by extension, to those on their care teams.

The ASA also wishes to define two different activities that happen after a serious adverse event. Failure to recognize the purpose of a conversation up front can lead to frustration and worsened emotional hurt. This includes:

1. Event review: This is defined as “just the facts” and should be performed promptly and with as little judgement as possible. Obtaining the timeline, circumstances, equipment, drugs, and proper documentation for later analyses should occur during this stage. It is not intended to support staff or salve their feelings. 
2. Peer support: This includes active listening and validation of emotional reactions to an event. The purpose is to provide perspective and context to help someone process and heal. Generally, these discussions are not protected under peer-review. 

The second victim syndrome is marked by the caregiver being traumatized by the triggering event(s), with resultant psychological sequelae similar to other types of traumatic experiences. It is most often experienced by healthcare providers who hold themselves partially responsible following an unexpected patient morbidity or mortality,¹  but has also been used to describe healthcare providers who struggle with adverse outcomes possibly resulting from medical errors, long working hours, under-supported medical practices, a lack of psychological support after a patient fatality or major adverse event,² or a combination of these factors. In addition to primary caregivers, second victims may include colleagues called in to assist during an acute event, support personnel, students, and others who may have been involved in the event or the immediate aftermath.³  The emotional distress experienced by a second victim can still occur whether the patient outcome was expected or unexpected, or whether that clinician made a critical error or not. 

Second victims often experience fear, guilt, self-doubt, shame, anger, re-living of the event, sleep disturbance, and anxiety.^4,5  These emotions mirror symptoms of acute stress disorder and post-traumatic stress disorder, and this may affect the physical and emotional well-being of the anesthesiologist both at work and at home. Such emotions may persist for weeks to years, and may contribute to burnout, substance abuse, and even suicide. In a national survey of the impact of perioperative catastrophes on anesthesiologists, over 60% of respondents experienced depression, while 19% indicated that they never fully recovered from the experience.⁵ While anesthesiologists have been recognized to be at higher risk of suicide and substance abuse than physicians in other specialties,^6,7  acute stress resulting from an adverse event or medical error can exacerbate this risk.

These second victim effects following adverse events and medical errors may also affect anesthesiologists’ ability to provide safe patient care. In a national survey, two-thirds of anesthesiologist respondents believed that their ability to provide patient care was compromised in the first 4 hours after an adverse event.⁵ This can result in a third victim, the patient subsequently cared for by the affected anesthesiologist.⁸

How to help Anesthesiologists Impacted by Workplace-Related Stress

Coping Strategies

In the immediate aftermath of an adverse event or other critical incident, anesthesiologists may have a variety of responses. Some may be quick to recognize that they need some time away from work; others may wish to continue working as a way to move forward. While processing and re-living the event, many clinicians will experience significant emotional distress, difficulty sleeping, poor appetite, difficulty concentrating, and decreased self-confidence. While these reactions are expected following these types of events, understanding potential coping strategies can be helpful in mitigating longer-lasting effects.

Anesthesiologists’ most frequently used positive coping mechanisms involve seeking emotional support from peers, others on the surgical team, and spouses, significant others, family, and friends.⁵ Mitigation of stress may be possible if the event is able to be discussed in detail with a colleague, potentially turning the adverse event into a learning opportunity and leading to quicker recovery. 

Alternatively, negative coping strategies such as turning to alcohol or drugs can be very harmful. Multiple studies have suggested that anesthesia providers are at a higher risk of substance misuse and abuse,^6,9,10,11  and strong evidence suggests that adverse occupational events increase this risk.^12,13,14,15 

Modifications to patient care by the second victim often occur after such precipitating events. While some are constructive, such as heightened attention to detail or seeking of assistance early, others are maladaptive such as over-ordering of tests and practicing medicine defensively.^4,16 

Given the emotional and cognitive effects of critical adverse events, duty relief should be offered to anesthesiologists and members of the anesthesia care team who were involved in such events. While it may be difficult to guarantee timely duty relief in every circumstance given the needs of other patients, every effort should be made to allow affected clinicians to remove themselves from the clinical care environment for the remainder of the day, and perhaps longer depending on the circumstances. Even if this requires calling in additional personnel or extending duties of other staff members, duty relief following critical adverse events should be treated similarly to family emergencies and other urgent situations in which relief would be offered without repercussions. Furthermore, such relief should be granted as proximal to the event as possible so as to ensure prompt emotional and psychological relief. Second victims should not be subject to indirect or direct penalties or consequences, including actions that may affect their clinical schedules or their salary.

Peer Support and Employee Assistance Programs

The development and implementation of formal peer support programs have increased as the second victim phenomenon has gained attention. One such well-known program was developed by an anesthesiologist who experienced the emotional consequences described following care of a patient who experienced a life-threatening event.¹⁷  After being implemented throughout a large academic medical center, the program has grown to support all clinicians with the fear, uncertainty, and distress that follow critical adverse events. Over the last decade, the program has also been expanded to support clinicians and others with other stressful situations, including malpractice litigation and personal crises.¹⁸  Other institutions have also demonstrated highly successful multidisciplinary peer support programs.¹⁹ 

Successful peer support programs have mechanisms to immediately identify critical events that may result in second victims. Once identified, such programs quickly deploy credible peer supporters familiar with the common reactions to such events and trained in offering “emotional first aid.”¹⁶ Strict confidentiality between peer supporters and affected clinicians is ensured in order to maintain trust, privacy, and continued service of such programs. The most successful amongst these initiatives are focused on building resilience and cannot be used in a manner that could be viewed in any way as punitive.

Peer supporters should be familiar with resources that might be available within the local environment, such as formal Employee Assistance Programs and mental health professionals. Peer supporters should similarly recognize that their roles as compassionate listeners and facilitators are limited and supports should be able to identify situations when affected clinicians may need referral to mental health professionals.

References:

¹ Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000 Mar 18;320(7237):726-7. doi: 10.1136/bmj.320.7237.726. PMID: 10720336; PMCID: PMC1117748.
² Ozeke O, Ozeke V, Coskun O, Budakoglu II. Second victims in health care: current perspectives. Adv Med Educ Pract. 2019 Aug 12;10:593-603. doi: 10.2147/AMEP.S185912. PMID: 31496861; PMCID: PMC6697646.
³ Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider "second victim" after adverse patient events. Qual Saf Health Care. 2009 Oct;18(5):325-30. doi: 10.1136/qshc.2009.032870. PMID: 19812092.
⁴ Seys D, Wu AW, Van Gerven E, Vleugels A, Euwema M, Panella M, Scott SD, Conway J, Sermeus W, Vanhaecht K. Health care professionals as second victims after adverse events: a systematic review. Eval Health Prof. 2013 Jun;36(2):135-62. doi: 10.1177/0163278712458918. Epub 2012 Sep 12. PMID: 22976126.
⁵ Gazoni FM, Amato PE, Malik ZM, Durieux ME. The impact of perioperative catastrophes on anesthesiologists: results of a national survey. Anesth Analg. 2012 Mar;114(3):596-603. doi: 10.1213/ANE.0b013e318227524e. Epub 2011 Jul 7. PMID: 21737706.
⁶ Bryson EO, Silverstein JH. Addiction and substance abuse in anesthesiology. Anesthesiology. 2008 Nov;109(5):905-17. doi: 10.1097/ALN.0b013e3181895bc1. PMID: 18946304; PMCID: PMC2766183.
⁷ Rose GL, Brown RE Jr. The impaired anesthesiologist: not just about drugs and alcohol anymore. J Clin Anesth. 2010 Aug;22(5):379-84. doi: 10.1016/j.jclinane.2009.09.009. PMID: 20650388.
⁸ Martin TW, Roy RC. Cause for pause after a perioperative catastrophe: one, two, or three victims? Anesth Analg. 2012 Mar;114(3):485-7. doi: 10.1213/ANE.0b013e318214f923. PMID: 22358047.
⁹ Booth JV, Grossman D, Moore J, Lineberger C, Reynolds JD, Reves JG, Sheffield D. Substance abuse among physicians: a survey of academic anesthesiology programs. Anesth Analg. 2002 Oct;95(4):1024-30, table of contents. doi: 10.1097/00000539-200210000-00043. PMID: 12351288.
¹⁰ Cicala RS. Substance abuse among physicians: What you need to know. Hospital Physician. 2003 39(7):39-46.
¹¹ Collins GB, McAllister MS, Jensen M, Gooden TA. Chemical dependency treatment outcomes of residents in anesthesiology: results of a survey. Anesth Analg. 2005 Nov;101(5):1457-1462. doi: 10.1213/01.ANE.0000180837.78169.04. PMID: 16244010.
¹² Harrison R, Lawton R, Perlo J, Gardner P, Armitage G, Shapiro J. Emotion and coping in the aftermath of medical error: a cross-country exploration. J Patient Saf. 2015 Mar;11(1):28-35. doi: 10.1097/PTS.0b013e3182979b6f. PMID: 25695552.
¹³ Gold MS, Byars JA, Frost-Pineda K. Occupational exposure and addictions for physicians: case studies and theoretical implications. Psychiatr Clin North Am. 2004 Dec;27(4):745-53. doi: 10.1016/j.psc.2004.07.006. PMID: 15550291.
¹⁴ Sinha R. How does stress increase risk of drug abuse and relapse? Psychopharmacology (Berl). 2001 Dec;158(4):343-59. doi: 10.1007/s002130100917. Epub 2001 Oct 26. PMID: 11797055.
¹⁵ Sinha R. Stress and addiction: a dynamic interplay of genes, environment, and drug intake. Biol Psychiatry. 2009 Jul 15;66(2):100-1. doi: 10.1016/j.biopsych.2009.05.003. PMID: 19555787; PMCID: PMC2730917.
¹⁶ van Pelt M, Blackney K, Morris T, Peterfreund R. Second Victim in Anesthesiologists. In Gastao FDN, editor. Occupational Well-being in Anesthesiologists. Rio de Janeiro: Brazilian Society of Anesthesiology, 2018.
¹⁷ van Pelt F. Peer support: healthcare professionals supporting each other after adverse medical events. Qual Saf Health Care. 2008 Aug;17(4):249-52. doi: 10.1136/qshc.2007.025536. PMID: 18678720.
¹⁸ Shapiro J, Galowitz P. Peer Support for Clinicians: A Programmatic Approach. Acad Med. 2016 Sep;91(9):1200-4. doi: 10.1097/ACM.0000000000001297. PMID: 27355784.
¹⁹ Edrees H, Connors C, Paine L, Norvell M, Taylor H, Wu AW. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. BMJ Open. 2016 Sep 30;6(9):e011708. doi: 10.1136/bmjopen-2016-011708. PMID: 27694486; PMCID: PMC5051469.