A superb article by Dr. Sumit Ghosal on a little known topic - Second Victim. For the longest time in the past, the entire hospital ecosystem would close ranks and somehow try to conceal the event and protect the healthcare professional from the blame. However, in recent years, with a growing emphasis on accreditation and the quality of healthcare services and regulatory requirements for reporting mishaps, institutional cover-ups have become increasingly difficult. What is happening instead ls that a particular member of the staff is singled out for the blame, with very little support from the management. In international literature on hospital administration, this member of the healthcare staff is described as the Second Victim (the first being the patient who sustains the injury caused by the mistake).

1. LITTL[SUPPORTFOR
JS[CONDVICTIMS
Evenexperienced,well-intentionedclinicianscanfalterintheirwork.
Buthowtodealwithunanticipatedmedicaleventsremainsanopenquestion
DR SuMIT GHOSHAL
n an Ideal world, pat`ents entenng
a hospital would benefit from the
heal.ing touch of doctors, nurses, other
healthcare orofessionals, etc. and would
emerge ln a much better conditlon
than before While this `ndeed happens
ln a majorlty of cases, a disconcerting
number suffer significant harm or even
die on account of mistakes of healthcare
staff at all levels,
According to one estimate publ`shed
by the US Instltute of Medicine, some
98,000 people in that country dled
each year because of serious blunders
committed by the doctors and other
staff. "That f`gure hcilds good even
now,'' says Dr K Sankaranarayanan,
an international surveyor with the
Joint Commission lnternatlonal
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regulator JCAHO (Joint Commisslon
for Accreditation Of Healthcare
Organisatlons). It can easily be
imagined that the number of US
patients whci suffered grlevous
•injury because of iatrogenlc
causes could be much higher.
Dr Giridhar Gyanl, the
founder of NABH (National
Accreditation Board for
Hospltals) and the Director
General cif Association
of Healthcare Providers
of India (AHpl), says the
total number of people in
India who suffer annually
on account of adverse
52 / FUTURE MEDICINE / J
I

2. medical occurrence could be as high
as 5.2 million! This includes all manner
of events, such as wrong medication,
patient falls, hospital-acquired lnfectjons
etc, he adds.
Difficult to cover up
For the longest time in the past, the
entire hospital ecosystem would close
ranks and somehow try to conceal
the event and protect the healthcare
professional from the blame. However,
in recent years, with a growjng emphasis
on accredjtation and the ciualjty of
healthcare services and regulatory
reciuirements for reporting mishaps,
institutional cover-ups have become
lncreasingly difficult. What is happening
instead ls that a particular member of
the staff is sjngled out for the blame,
with very little support from the
management. In international literature
on hospital administration, this member
of the healthcare staff is described as
the Second Victim (the first being the
patient who sustains the injury caused
by the mistake).
Discussing the topic at a conference
of the Consor[lum of Accredited
Healthcare Organisations (CAHO) held in
Mumbai recently, Dr Sankaranarayanan
explained that the Second Victims
involved in a -sentinel event" with regard
to patient safety had to be handled
with extreme care. Sentinel events are
major events that have to be reported
compulsorily to the top management for
appraisal of quality-related performance
of the institution.
"The episode is usually followed
by a severe stress response if the
error is serious and has resulted in
death c)r grievous injury to the patient
concerned," Dr Sankaranarayanan
said, adding that the health worker.s
respc)nse comes in several stages: First,
there is denial or djstancing (oneself
from the event), followed by a state
of shock when the blame cannot
be avoided and finally. a long-term
response which can be self-doubt. a loss
of confidence or a shift to a less critical
job. Often, this cc)uld mean that a highly
trained human resource such a heart
surgeon could swjtch to being a famHy
physician.
The phenomenon would not have
grabbed so much attention of the
top management of major hospitals
if it were a rare occurrence. affecting
only a small number of healthcare
professionals. But Lt Colonel (Dr)
Madhav Madhusudan Singh, secretary
of the RFHHA (Research Foundation for
Hospital and Healthcare Administration)
ciuotes one survey which says that one
in every seven healthcare professionals
I,E/I have been conducting a
study on this subject over
the past three years, jn
/ which I have interviewed
approximately 300 Indian
clinicians on this subject,
and as many as 145 of them
admitted that they had gone
through such an experience.
Lt Colonel (Dr) Madhav
Madhusudan Singh
Secretary, RFHHA
(175/1160) becomes a Second Victim
sometime during their career. "I have
been conducting a study on this subject
over the past three years. in which I
have jntervjewed approximately 300
Indian clinicjans on this subi.ect, and as
many as 145 of them admitted that they
had gone through such an experience,"
Lt Col. Singh says.
Manifold trauma
He also reported that about 20 percent
of his subjects Could not sleep for about
7-10 days after each epjsode of severe
medical errors, particularly because
most c)f the affected clinicians were
relatively young and inexperienced.
When auestionec) further as to the
cause of the medical error, almost 70
percent blamed themselves (and were
filled with shame and self-doubt),
while the remaining 30 percent held
their organizations responsible for
the overlc)ad of work. Investigations
of unantlcipated clinical events often
reveal that experienced and well-
intentioned clinlcians can falter because
of complex clinical conditions, poorly
designed processes and inadequate
communication patterns, he added.
According to a March 2018 article in
the Indian Journal of Surgical Oncology,
the trauma of the Seconcj Victim ls
compounded or worsened manifold by
the allegations of medical negligence
and the legal proceedings that follow
in state medical cc)unclls or in the
courts. "Hence, the formulation of an
awareness campaign will promote an
open dialogue about the prevalence
of Second Victims among our fellow
professionals,n the artlcle says Besides,
the development of surveillance, support
strategies and the setting up c)f help-
desks at various healthcare facilities
wc)uld further help to mjtigate the
situation.
In a separate interview with
Fiiture Medicine, Dr Sankaranarayanan
also emphasized that the hospital
management were expectecl tc) offer
a nuanced response, depending upon
the nature and severity of the mistake
made by the employee concerned. Thus,
a single mjstake, which ap|]eared to be
a genuine accident, could be dealt with
through counseling and retraining by
peers rather than superiors. However,
a serious error, provoked by exhaustion
or any other Physical factors, could
be avoided in the future by suitable
corrective action. On the other hand,
defiance on the part of the employee.
or a refusal to bring about the required
improvements despite adequate
opportunities, should surely attract
punishment. E
June 2019 / FUTURE ivlEDICINE / 53