Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations

Abstract

Purpose: To summarize the knowledge about the aftermath of adverse events (AEs) and develop a recommendation set to reduce their negative impact in patients, health professionals and organizations in contexts where there is no previous experiences and apology laws are not present.

Data sources: Review studies published between 2000 and 2015, institutional websites and experts' opinions on patient safety.

Study selection: Studies published and websites on open disclosure, and the second and third victims' phenomenon. Four Focus Groups participating 27 healthcare professionals.

Data extraction: Study characteristic and outcome data were abstracted by two authors and reviewed by the research team.

Results of data synthesis: Fourteen publications and 16 websites were reviewed. The recommendations were structured around eight areas: (i) safety and organizational policies, (ii) patient care, (iii) proactive approach to preventing reoccurrence, (iv) supporting the clinician and healthcare team, (v) activation of resources to provide an appropriate response, (vi) informing patients and/or family members, (vii) incidents' analysis and (viii) protecting the reputation of health professionals and the organization.

Conclusion: Recommendations preventing aftermath of AEs have been identified. These have been designed for the hospital and the primary care settings; to cope with patient's emotions and for tacking the impact of AE in the second victim's colleagues. Its systematic use should help for the establishment of organizational action plans after an AE.

Keywords: medical errors; nurses; organizational policy; patient safety; physicians; professional–patient relations; safety management; second victim; third victim.