Anestezi ve Yoğun Bakımda İkinci Mağdur (Kurban) Olgusu

Year 2023, Volume: 2 Issue: 2, 45 - 50, 19.06.2023

Pınar Ayvat , Gülşah Şehitoğlu Alpağut , Kamil Aşar , Aysel Başer , Can Özlü , Ayşe Ejderoğlu

https://doi.org/10.57221/izmirtip.1229742

Abstract

Sağlık hizmet sunumu, hata payının ve istenmeyen olayların en az olması istenen hizmet sektörüdür. Ancak uygulanan tedaviler ve girişimler sırasında istenmeyen olayların meydana gelmesi kaçınılmazdır. Bu gibi durumlarda hasta ve hasta yakınları birincil mağdur (kurban) olarak adlandırılırken, bu gibi olayla karşılaşan sağlık çalışanı da ikinci mağdur (kurban) konumuna düşmektedir. Çeşitli faktörlerin etkisi ile ikinci mağdur olgusu yaşama sıklığı kişiden kişiye değişse de özellikle pandemiden dolayı yıpranmış ve tükenmiş sağlık çalışanları advers olaylara karşı daha hassas bir dönemde bulunmaktadır. Ameliyathane ve yoğun bakımlar ise yüksek mortalite ve morbidite oranı olan, yoğun çalışma temposuyla ve gece vardiyası ile çalışılan, aciliyetin ve hızlı karar vermenin gerektiği alanlardır. Bu alanda çalışan sağlık personelinin, sonu ölüme kadar giden advers olaylardan etkilenme ihtimali daha yüksektir. Avrupa ve Amerika’da pek çok tıp merkezi ikinci mağdur durumunda sağlık personelini desteklemek için politikalar geliştirmiştir. Ancak Türkiye’de bu konu hala bilinmemekte ve bu konuda herhangi bir yayın bulunmamaktadır. Bu derleme anestezi ve yoğun bakım alanında görev yapan sağlık personelinin ikinci mağdur konusundaki farkındalığını arttırmak için yazılmıştır.

Keywords

Anestezi, yoğun bakım, advers olay, ikinci mağdur olgusu

Thanks

Yöneticisi olduğu “İkinci Mağdurlar Üzerinde Çalışan Avrupalı Araştırmacılar Ağı” isimli COST projesi ile farkındalığımızı arttıran ve bu derlemeyi yazmak için bizi cesaretlendiren değerli hocamız Prof José Joaquín Mira (PhD) ’ya teşekkürlerimizi sunmak isteriz. We would like to thank our esteemed professor Prof José Joaquín Mira (Ph.D.) for raising our awareness with the COST project titled "European Researchers' Network Working on Second Victims" of which he is the manager and encouraging us to write this review.

THE SECOND VICTIM PHENOMENON IN ANESTHESIA AND INTENSIVE CARE

Abstract

Health service delivery is the service sector in which the margin of error and undesirable events are desired to be the least. However, it is inevitable that undesirable events occur during the treatments and interventions. In such cases, the patient and patient relatives become the primary victims, while the health worker who encounters such an event falls into the position of the second victim. Although the frequency of experiencing a second victim case due to the effect of various factors varies from person to person; Healthcare professionals,especially those who are depleted and exhausted due to the pandemic, are more vulnerable to adverse events. On the other hand, operating rooms and intensive care units are areas with high mortality and morbidity rates, working with intense working tempo and night shifts, where urgency and quick decision-making are required. Healthcare personnel working in this field are more likely to be affected by adverse events leading to death. Many medical centers in Europe and America have developed policies to support healthcare personnel in the case of second victims. However, this issue is still unknown in Turkey and there is no publication on this subject. This review was written to increase the awareness of the health personnel working in the field of anesthesia and intensive care about the second victim.

Keywords

Anesthesia, intensive care, adverse event, second victim phenomenon

References

• Referans1. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 991;324:377-84.
• Referans2. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG et al. Incidence of adverse events and negligence in hospitalized patients. New Engl J Med. 199;324:370-6.
• Referans3. (Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000. PMID: 25077248.
• Referans4. Van Pelt F. Peer support: healthcare professionals supporting each other after adverse medical events. Qual Saf Health Care. 2008;17:249-52.
• Referans5. Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N et al. Global trigger tool” shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Mildwood) 2011;30:581-9.
• Referans6. Soop M, Fryksmark U, Köster M, Haglund B. The incidence of adverse events in Swedish hospitals: a retrospective medical record review study. Int J Qual Health Care. 2009;21:285-91.
• Referans7. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9:122-8. Referans8. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016; 353: i2139.
• Referans9. Wilson RM, Michel P, Olsen S, Gibberd RW, Vincent C, El-Assady R et al. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. BMJ. 2012;344:e832.
• Referans10. Ullström S, Sachs MA, Hansson J, Øvretveit J, Brommels M. Suffering in silence: a qualitative study of second victims of adverse events. BMJ Qual Saf. 2014;23:325-31. Referans11. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-7.
• Referans12. Edrees HH, Paine LA, Feroli R, Wu AW. Health care workers as second victims of medical errors. Pol Arch Med Wewn. 2011;121:101-8.
• Referans13. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care. 2009;18:325-30.
• Referans14. Manser T. Managing the aftermath of critical incidents: meeting the needs of health-care providers and patients. Best Pract Res Clin Anaesthesiol. 2011;25:169-79.
• Referans15. Seys D, Scott S, Wu A, Van Gerven E, Vleugels A, Euwema M et al. Supporting involved health care professionals (second victims) following an adverse health event: a literature review. Int J Nurs Stud. 2013;50:678-87.
• Referans16. Mira JJ, Carrillo I, Lorenzo S, Ferrús L, Silvestre C, Pérez-Pérez P et al. The aftermath of adverse events in Spanish primary care and hospital health professionals. BMC Health Serv Res. 2015;15:151-60.
• Referans17. Gazoni FM, Amato PE, Malik ZM, Durieux ME. The impact of perioperative catastrophes on anesthesiologists: Results of a national survey. Anesth Analg. 2012;114:596-603.
• Referans18. Dornette W, Ortho O. Death in the operating room. Curr Res Anesth Analg. 1956;35:545-69.
• Referans19. Seys D, Wu AW, Gerven E Van, Vleugels A, Euwema M, Panella M et al. Health care professionals as second victims after adverse events: a systematic review. Eval Health Prof. 2012;36:135-62. Referans20. Scott SD, Hirschinger LE, Cox KR, McCoig M, Hahn Cover K, Epperly KM et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010;36:233-40.
• Referans21. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001-7.
• Referans22. Sirriyeh R, Lawton R, Gardner P, Armitage G. Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals’ psychological well-being. Qual Saf Health Care. 2010;19:e43–e43. Referans23. Wolf ZR, Serembus JF, Smetzer J, Cohen H, Cohen M. Responses and concerns of healthcare providers to medication errors. Clin Nurse Spec. 2000;14:278-90.
• Referans24. West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296:1071-8.
• Referans25. Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600-13.
• Referans26. Quillivan RR, Burlison JD, Browne EK, Scott SD, Hoffman JM. Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses. Jt Comm J Qual Patient Saf. 2016;42:377-84.
• Referans27. Krzan KD, Merandi J, Morvay S, Mirtallo J. Implementation of a “second victim” program in a pediatric hospital. Am J Health Syst Pharm. 2015;72:563- 7.
• Referans28. Burlison JD, Quillivan RR, Scott SD, Johnson S, Hoffman JM. The Effects of the second victim phenomenon on work-related outcomes: connecting self-reported caregiver distress to turnover intentions and absenteeism. J Patient Saf. 2021;17:195-9.
• Referans29. Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007;33:467-76.
• Referans30. Warltier DC, Lagasse RS. Anesthesia safety: model or myth?A review of the published literature and analysis of current original data. Anesthesiology. 2002;97:1609-17.
• Referans31. White SM, Akerele O. Anaesthetists’ attitudes to intraoperative death. Eur J Anaesthesiol. 2005;22:938-41. Referans32. Gazoni FM, Durieux ME, Wells L. Life after death: The aftermath of perioperative catastrophes. Anesth Analg. 2008;107:591-600.
• Referans33. Nijs K, Seys D, Coppens S, Van De Velde M, Vanhaecht K. Second victim support structures in anaesthesia: a cross-sectional survey in Belgian anaesthesiologists. Int J Qual Heal Care. 2021;33:1–7.
• Referans34. Lander LI, Connor JA, Shah RK, Kentala E, Healy GB, Roberson DW. Otolaryngologists’ responses to errors and adverse events. Laryngoscope. 2006;116:1114-20.
• Referans35. Venus E, Galam E, Aubert JP, Nougairede M. Medical errors reported by French general practitioners in training: results of a survey and individual interviews. BMJ Qual Saf. 2012;21:279-86. Referans36. Harrison R, Lawton R, Stewart K. Doctors’ experiences of adverse events in secondary care: the professional and personal impact. Clin Med. 2014;14:585-90.
• Referans37. Cauldwell M, Chappell LC, Murtagh G, Bewley S. Learning about maternal death and grief in the profession: a pilot qualitative study. Acta Obstet Gynecol Scand. 2015;94:1346-53. Referans38. Nevalainen M, Kuikka L, Pitkälä K. Medical errors and uncertainty in primary healthcare: A comparative study of coping strategies among young and experienced GPs. Scand J Prim Health Care. 2014;32:84-9.
• Referans39. Vaithilingam N, Jain S, Davies D. Helping the helpers: debriefing following an adverse incident. Obstet Gynaecol. 2008;10:251-6.
• Referans40. Hobgood C, Hevia A, Tamayo-Sarver JH, Weiner B, Riviello R. The influence of the causes and contexts of medical errors on emergency medicine residents’ responses to their errors: an exploration. Acad Med. 2005;80:758-64.
• Referans41. Engel K, Rosenthal M, Sutcliffe K. Residents’ responses to medical error: coping, learning, and... : academic medicine. Acad Med. 2006;81:86-93.