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

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.

The Second Victim Phenomenon After a Clinical Error: The Design and Evaluation of a Website to Reduce Caregivers' Emotional Responses After a Clinical Error.

Background: Adverse events (incidents that harm a patient) can also produce emotional hardship for the professionals involved (second victims). Although a few international pioneering programs exist that aim to facilitate the recovery of the second victim, there are no known initiatives that aim to raise awareness in the professional community about this issue and prevent the situation from worsening.

Objective: The aim of this study was to design and evaluate an online program directed at frontline hospital and primary care health professionals that raises awareness and provides information about the second victim phenomenon.

Qualitative Study About the Experiences of Colleagues of Health Professionals Involved in an Adverse Event.

Objectives: Identify what occurs among health-care providers (HCPs) after an adverse event (AE) and what colleagues could do to help them.

Method: A qualitative study with participation by physicians and nurses from hospitals and primary care facilities.

Results: Fifteen HCPs and 12 health professionals with quality management responsibilities with between 8 and 30 years of experience participated; 15 (56%) were physicians (9 general practitioners, 3 surgeons, 2 intensivists, and 1 from an emergency unit), and 12 (44%) were nurses (5 worked in primary care and 7 in hospitals).

Design and Testing of BACRA, a Web-Based Tool for Middle Managers at Health Care Facilities to Lead the Search for Solutions to Patient Safety Incidents.

Background: Lack of time, lack of familiarity with root cause analysis, or suspicion that the reporting may result in negative consequences hinder involvement in the analysis of safety incidents and the search for preventive actions that can improve patient safety.

Objective: The aim was develop a tool that enables hospitals and primary care professionals to immediately analyze the causes of incidents and to propose and implement measures intended to prevent their recurrence.

Methods: The design of the Web-based tool (BACRA) considered research on the barriers for reporting, review of incident analysis tools, and the experience of eight managers from the field of patient safety.

What, who, when, where and how to inform patients after an adverse event: a qualitative study.

Objective: To explore suggestions and recommendations for conducting open disclosure with a patient after an adverse event in a setting without professionals' legal privileges.

Method: Qualitative study conducting focus groups/Metaplan. This study was conducted with physicians and nurses from Primary Care and Hospitals working in the public health system in Spain.

Interventions in health organisations to reduce the impact of adverse events in second and third victims.

Background: Adverse events (AE) are also the cause of suffering in health professionals involved. This study was designed to identify and analyse organization-level strategies adopted in both primary care and hospitals in Spain to address the impact of serious AE on second and third victims.

Methods: A cross-sectional study was conducted in healthcare organizations assessing: safety culture; health organization crisis management plans for serious AE; actions planned to ensure transparency in communication with patients (and relatives) who experience an AE; support for second victims; and protective measures to safeguard the institution's reputation (the third victim).

The aftermath of adverse events in Spanish primary care and hospital health professionals.

Background: Adverse events (AEs) cause harm in patients and disturbance for the professionals involved in the event (second victims). This study assessed the impact of AEs in primary care (PC) and hospitals in Spain on second victims.

Methods: A cross-sectional study was conducted.