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Prof. Reinhard Strametz holds the chair for patient safety at RheinMain University in Wiesbaden/Germany. Before that, he worked as an anesthesiologist at Frankfurt University Hospital and was Chief Quality Officer of this hospital. For over than twenty years, as both a doctor and an economist, he has been interested in aspects of quality and clinical risk management and today has the honor of heading the Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP).

Why does Patient Safety and, more specifically, the topic “Leadership, team and organisational performance” personally matter to you?

Over the last two decades, we have learned a lot about tools for mitigating clinical risks, especially in hospital care. But sometimes these tools work well in one place and fail miserably in many others. The main reason for this is not the way in which they have been used, but because some medical facilities do not have a sufficient safety culture. In addition, secure communication and sufficient team performance will play a key role in the successful implementation of patient safety measures. But what is the basis for this to happen?

Initially, we talked about the “error culture” that needed to be improved, but today we focus more on concepts of High-Reliability Organisations and Safety Culture. The latter can be seen as the goal of our efforts, but to some extent it is also a prerequisite for the success of our efforts, the fertilizer, so to speak, for the still tender seedling of patient safety in many organisations.

And who will create the culture? Whose responsibility is it to ensure that an appropriate safety culture takes root in facilities? That’s right, it’s the job of the leaders. It’s one of the most important and noblest duties of healthcare leaders. 

“One of the most important and noblest duties of healthcare leaders is to ensure that an appropriate safety culture takes root in their facilities.”

What exactly is “second victim support”? Do you know of any examples of such support systems in the field? What is your experience in this area?

A Second Victim can be defined as any health care worker who is directly or indirectly involved in an unanticipated adverse patient event, an unintentional healthcare error, or a patient injury and who becomes a victim in the sense that he or she also suffers negative consequences.

This is a genuine human reaction and evidence shows that the majority of health care workers are already second victims. The problem with this human reaction is that, without proper support, it will lead to dysfunctional coping strategies like self-stigmatisation, loss of self-confidence, substance abuse or the practice of defensive medicine. Worse still, those affected might develop serious mental health conditions such as post-traumatic stress disorder (PTSD) or depression. This is a serious hazard to health worker safety but also to patient safety as the likelihood of making (additional) mistakes increases dramatically. Without sufficient and timely support, this can become a vicious circle.

On the other hand, we know that particularly early support during the experience of the second victim phenomenon is very likely to lead to complete recovery or even fulfilment. We have to acknowledge that the treatment of PTSD is very effective, but only at an early stage of this condition. As the second victim phenomenon is clearly linked to occupational circumstances and therefore consitutes an occupational hazard, programs to support second victims should be implemented as part of health promotion and prevention programs in. the workplace in any healthcare institution.

There are a few flagship projects in Europe, such as KoHi in Vienna/Austria, MISE in Spain or PSU-Helpline in Germany, but we are still miles away from a comprehensive solution in all healthcare institutions in Europe, such as the one already implemented for needle-stick injuries, for example.

“The majority of health care workers are already second victims.”

Is this an easy subject to tackle in the field? Doesn’t it run against the culture of the super-carer, who deals with every situation?

That is a very valid point. During our research, we identified three major barriers to overcome, which lie within ourselves. 

Firstly, we are trained to be the healthiest, to be heroic and to cope with every situation. But sooner or later we will find out that beyond sleep deprivation, loss of social contacts outside our healthcare institution and, of course a considerable amount of resilience, we  remain human beings with natural limits. 

To overcome these inhibitions, the peer support by colleagues has proved very effective. It would be more difficult to admit, as a “bulletproof” doctor, that I need the help from a psychologist. Another advantage is that my colleague also knows my situation very well and probably may have experienced a similar one him- or herself.

The second barrier is related to our training to be confident and to show confidence to our patients. The risk of being overconfident is inherent. We hypothesised that a significant proportion of medical doctors and nurses who are overconfident in their ability to adapt would underestimate the risk of becoming second victims and, unfortunately, we were able to confirm this.A third barrier is also related to our socialisation. When asked about their knowledge on the Second Victim Phenomenon before assessing their own symptom load, only a minority of doctors and nurses had ever heard of it, which may explain the self-stigma, which can also be seen as a potential barrier to accepting help, as they might feel they do not deserve support. This phenomenon and evidence-based ways to prevent or mitigate its potential effects should therefore be taught as part of our basic medical education.

What are the advantages of such support systems?

Besides acute care provided to second victims, implementing such programs will also increase the psychological safety of staff, which is a cornerstone of effective teamwork and mitigation of clinical risks.

Implementing such programs is therefore a triple win: Firstly, healthcare workers will benefit from increased psychological safety as well as sufficient primary and secondary prevention. Secondly, our patients will benefit from a reduced risk of errors leading to harmful preventable adverse events, which, according to numerous OECD reports, will also save huge amounts of money. Thirdly, the healthcare organisation will benefit from reduced staff turnover, which in our economic simulations also pays off very well.

Implementing such programs should therefore be considered as a no-brainer as they can improve the  quality of care while reducing costs, with a high return on investment. 

What are the key points to bear in mind when implementing them?

Support programs, like any implementation in healthcare, need to be evidence-based, contextualised and facilitated, for example by honest communication about the issue and explicit leadership. If our role-models admit that this is a serious problem that sooner or later will affect everyone in the business, they will be able to overcome the taboo, that still exists in many institutions. 

Successful programs will include both peer support of trained and sensitized colleagues and professional support that will be available in a timely manner. But apart from treatment of second victims, those programs should start before in creating psychological safety by creating a safety culture in which self-care is not regarded as selfishness but as an expression of professionalism.

We should always remember what is said in the World Medical Association Declaration of Geneva: “I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard… I MAKE THESE PROMISES solemnly, freely, and upon my honour”

Do you see a link between the widespread implementation of support programs and any general issues or crises that could affect healthcare systems and patient safety?

The greatest challenge facing healthcare systems around the world is maintaining their capacity in terms of staff. We are in the midst of a huge staffing crisis, seeing many trained healthcare workers to either leave their countries to make up for shortages elsewhere or to even drop out of the healthcare system.

By creating a culture of safety and support, we can fight this crisis, which will otherwise lead to the collapse of healthcare systems in the near future. It is not about bringing more and more people into our healthcare systems and burning them out, but about keeping those who are already in the system healthy and safe. Because if we don´t care for them now, they won´t care for us in the future. 

Prof. Dr. Reinhard Strametz
Wiesbaden Institute for Healthcare Economics and Patient Safety (Germany)
Why and how to design a safety-oriented organization?