AHRQ Director: Systems Must Mitigate Damage to Patients and Second Victims

The right patient safety culture can make a significant different in mitigating damage for both patients and "second victims" after an adverse event has occurred, says Carolyn Clancy, MD, director of the Agency for Health Research and Quality.

Published research has shown the devastating effects adverse events can have on clinicians. Dr. Clancy cites an event that occurred at Seattle Children's Hospital last September. A nurse in the cardiac intensive care unit overdosed an 8-month-old patient, eventually leading to the baby's death. Dr. Clancy writes the nurse suffered professional and personally and later committed suicide.


Although the "name, blame and shame" approach has subsided somewhat with the emergence of patient safety organizations, which provide a system of reporting "without fear of legal discovery," healthcare organizations must do more to ensure emotional damage to second victims is minimized, Dr. Clancy writes.

"Health care institutions that have successfully instilled a patient safety culture may help their clinicians; those that haven't might unintentionally harm them," she says in the commentary.

Dr. Clancy's commentary on the need to alleviate harm to "second victims" first appeared in the Journal of Nursing Care Quality.

To read Dr. Clancy's commentary in full, click here.

Related Articles on Adverse Events:

Healthcare Providers Affected by Adverse Events Request Emotional Support, Peer Support

7 Guiding Principles for Designing a Successful Medication Reconciliation Process

Connecticut Report Shows Falls Among the Most Frequently Occurring Medical Errors

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