Action after Adverse Events in Healthcare: An Integrative Literature Review.

Area of Science:

• Healthcare Quality and Safety
• Patient Safety Research
• Medical Error Analysis

Background:

• Adverse events are frequent occurrences in healthcare settings.
• These events create multiple categories of victims: patients and families (first victims), healthcare professionals (second victims), and healthcare organizations (third victims).

Purpose of the Study:

• To synthesize existing knowledge, theory, and evidence on actions following adverse events.
• Focus on literature published between 2009 and 2018.

Main Methods:

• An integrative review methodology was employed.
• Critically evaluated 25 studies published within the specified ten-year period.

Main Results:

• Identified key themes for first victims: event disclosure, communication, support, and apology.
• Second victim themes included support services, coping strategies, professional impact, and learning.
• Third victim themes comprised organizational actions, strategy, infrastructure, training, and communication.

Conclusions:

• A significant lack of comprehensive models for post-adverse event action exists.
• Requires a holistic understanding and management approach to adverse events.
• Immediate, systematic damage-prevention actions are necessary upon event identification and concern expression, necessitating system-wide development.