Improving Patient Safety: The Intersection of Safety Culture, Clinician and Staff Support, and Patient Safety Organizations

Lessons from high reliability industries such as nuclear power and aviation are being adopted in healthcare. A key component of a high reliability organization is a culture of safety that relies upon trust, report and improvement. (Reason and Hobbs, 2003). One initiative gaining considerable recognition in promoting trust and providing clinician support is a Second Victim Intervention Program. This kind of intervention offers peer support to individual healthcare workers and professionals who are involved in, or victimized and traumatized by, an unanticipated adverse patient event, medical error, or a patient related injury. (MU Health forYOU Team). Second Victim Intervention Programs demonstrate respect of healthcare workers and an appreciation of the complexity and risk inherent in the healthcare work environment. Additionally, Second Victim Intervention Programs compliment patient safety program activities that assess culture, identify and report adverse events, disclose errors, support patients and families, and take action to reduce repeated errors. As pioneers of the Second Victim movement, MU Health patient safety researchers established the forYOU Team in 2007. Through a structured system of training, support, documentation and integration with the patient safety program, a dedicated team of frontline peer supporters serve as rapid responders who identify and support second victims. Having supported more than 1,360 second victims, the forYOU Team’s success continues building on trust that enables staff to seek help and healing. Confidentiality, a critical success factor for a Second Victim Intervention Program, must be ensured for peer supporters and second victims. An organization establishing a program and participating in a federally-designated Patient Safety Organization (PSO) can define the program within its Patient Safety Evaluation System (PSES). It can also define program documentation as Patient Safety Work Product (PSWP) to obtain federal level confidentiality protections available through the Patient Safety and Quality Improvement Act of 2005 (PSQIA). Opportunities to implement and integrate a Second Victim Intervention Program within an organization’s PSES through PSO participation (and next steps) are discussed within this paper.