Table 4

Summary characteristics of reviewed studies showing learning for leadership and culture

AuthorDatePlace of studyStudy purposeLearning for medical leadership and cultureParticipantsDesignPrimary
Anderson et al 10 2009USATo explore inaccuracy of medical error reporting, levels of discomfort reporting and physician’s own experience of personal injury while receiving medical care
  • Physicians with experience of family members who were injured reported errors or patient safety practices more frequently offering insights to the challenges of medical reporting.

Doctors: 319 Obstetricians and GynaecologistsQUANTITATIVE
Self report measures
Medical error disclosure
Asghari et al 12 2009IranTo evaluate doctor's attitudes towards handling medical errors made by their peers
  • The dominating culture in the profession makes it difficult to disclose medical errors to peers.

  • Doctors prefer to be informed of their errors and require education and guidance about how to handle peers' medical errors.

  • Adopting a non-judgemental approach towards a peer affected by medical error is important.

Doctors: 387 General PractitionersQUANTITATIVE
Response to a vignette
Medical error disclosure
Engel et al 35 2006USATo explore significant emotional challenges facing resident physicians when medical ‘mishaps’ occur and exploring their approaches to coping
  • Residents prefer to speak about medical error events with medical colleagues.

  • Supervisors (leaders) were perceived to have the knowledge, authority and experience to support and relieve the anxiety and stress experienced by the resident.

  • Interactions between physicians and supervisors (leaders) are critical to the coping process and leaders need to pay attention to blame responses within teams and encourage constructive and open discussion.

Doctors: 26 doctorsQUALITATIVE
In depth semi-structured interviews
Medical error disclosure
Ferrús et al 41 2016Spain, Catalonia, Basque CountryTo better understand the psychological stress of second victims and what colleagues can do to help them
  • Second victims require support from colleagues and leaders/managers. When not received victim experiences rejection.

  • Promotion of safety culture by leaders is required.

  • Colleagues react towards the adverse event with surprise ‘acting as if nothing has happened’ to avoid involvement resulting in stigmatisation for the second victim.

Mixed: 15 doctors, 12 nursesQUALITATIVE
In depth semi-structured interviews
Second Victim
Harrison et al 40 2013UK and USATo investigate professional/personal disruption experienced post error; emotional response and coping strategies used; and perceptions of organisational support
  • Support from peers was recognised as helpful but fears over confidentiality may prohibit some staff from accessing peer support.

Mixed: 61 doctors and 65 nurses (UK). 59 doctors and 80 nurses (USA)QUANTITATIVE
Self report questionnaire
Second Victim
Harrison et al 15 2014UKTo establish physicians’ experiences of adverse patient safety events and near misses, and the professional and personal impact of these
  • Greater responsibility be placed on Healthcare organisations, commissioners, policy makers, regulators and professional bodies to develop systems to support affected clinicians in order to foster the necessary open, transparent culture and to ensure that incident reporting becomes a learning activity.

Doctors: 1334 doctorsQUANTITATIVE
Self report questionnaire
Second Victim
Joesten et al 36 2015USATo establish a baseline of perceived availability of institutional support services or interventions and experiences following an adverse patient safety event
  • Non-punitive environment can be achieved by combining well-integrated support systems with a well-developed Just Culture.

  • A Just Culture is contributory to greater patient safety overall and possible healing for second victims.

  • In implementing a Just Culture, managers (Leaders) need to hold their direct reports to account without being unduly punitive.

Mixed: 12 doctors, 82 nurses and 21 otherQUANTITATIVE
Self report questionnaire
Second Victim
Loren et al 13 2008USATo describe, based on error appearance, whether paediatricians would disclose the error; apologise and provide information about future prevention
  • Supervising physicians to provide feedback and act as role models for trainees to observe.

  • Recommends the vertical integration of error disclosure training into medical education recommended.

  • Quality improvement opportunities exist within error disclosure practices and make these as well as professional guidelines and standards well known.

Doctors: 176 attending doctors and 29 medical traineesQUANTITATIVE
Response to a vignette
Medical error disclosure
Martinez and Lehmann11 2013USATo compare surgical and nonsurgical residents exposure to role modelling for responding to medical errors and their attitudes about disclosure
  • A ‘hidden curriculum’ exists in which a punitive response to errors is modelled by senior doctors in the healthcare team. These values and attitudes about error disclosure are ‘transmitted’ to trainees that observe them.

  • Cultures of safety within surgical and non-surgical learning environments to be promoted.

  • Institutional leaders should seek to identify poor cultural behaviours and thoughtfully confront physicians who model negative behaviours in response to errors.

  • Educational and hospital leaders should provide confidential means for all members to report physicians who exhibit a dysfunctional response to medical error and other disruptive behaviours.

  • Restriction of hospital privileges to those physicians who persistently exhibit disruptive behaviours.

  • Interdisciplinary and multilevel training in error disclosure to ensure shared understanding and normalise the discussion of medical error.

Doctors: 435 surgical and non-surgical residentsQUANTITATIVE
Self report questionnaire
Medical error disclosure
Martinez et al 37 2014USATo measure trainees exposure to negative and positive role modelling for responding to medial errors and to examine the association between that exposure and trainees attitudes and behaviours regarding error disclosure
  • Negative role-modelling is more influential than positive role-modelling for trainees.

  • Institutional leaders to ensure all physicians receive sufficient training in patient safety and error disclosure to allow them to function as effective and positive role models for responding to errors.

Doctors: 435 residents doctors and 1187 medical studentsQUANTITATIVE
Self report questionnaire
Medical error disclosure
May and Plews-Ogan38 2012USATo examine the role of talking (or remaining silent) in the physicians’ experience of coping with medical error
  • Helpful conversations for physicians coping with medical error promote learning and healing.

  • Barriers that healing conversations have on due to legal practices and institutional culture should be examined.

  • The ‘hidden curriculum’ in medicine encourages doctors to be silent about error. This should be overcome by developing skills in physicians to seek out (and provide) appropriate support for one another.

Doctors: 61 doctorsQUALITATIVE:
In depth semi-structured interviews
Second Victim
Mira et al 42 2015SpainTo assess the impact of adverse events in primary care and hospital setting on second victims
  • Role of colleagues and leaders post adverse event is crucial, particularly in the early stages and health professionals are not equipped with the necessary training to cope with the aftermath.

  • Addressing the number of potential numbers of second victims in primary and secondary care suggests that managers and leaders have ‘hardly begun to address this issue’.

  • Raising awareness and reinforcing a safety culture is recommended.

Mixed: 541 doctors, 495 nurses, 51 otherQUANTITATIVE
Self report questionnaire
Second Victim
Plews-Ogan et al 39 2016USATo explore what helps individual clinicians learn and adapt positively after making a harmful mistake
  • A cultural shift is required, through supportive acknowledgement of medical error and second victim and open discussion to help curb the effects on unspoken expectation of perfection.

  • Emphasising that most errors are not personal blemishes stemming from unacceptable fallibility but a natural consequence of being human.

  • Provide Doctors a trained 'peer and an ear' to ‘hold’ the feelings for the second victim and help physicians cope with an adverse events.

  • Enrich the curricula on ethics, humanism and spirituality in medicine to enhance Doctors own moral context.

  • Provide Doctors with experience of error teaching opportunities allowing them to pass on wisdom.

Doctors: 61 doctorsMIXED METHODS
Self report questionnaire and semi-structured interview
Second Victim
Scott et al 17 2009USATo explore, describe and characterise the experiences and recovery trajectory of past second victims
  • Institutional awareness campaigns promoting open dialogue about second victims that ask direct questions about safety experiences that result in psychological distress and whether institutional support was received.

  • Training frontline supervisors and peers to provide immediate and targeted support in early stages of recovery.

Mixed: 10 doctors, 11 nurses and 10 otherQUALITATIVE
In depth semi-structured interviews
Second Victim
Ullström et al 43 2014SwedenTo investigate how healthcare professionals are affected by their involvement in adverse events with emphasis on the organisational support they need and how well the organisation meets those needs
  • Impact on the healthcare professional was related to the organisation’s response to the adverse event.

  • Attention should be paid to organisational climate where these issues should be addressed and discussed in a non-judgemental manner.

  • Well-established support structures can meet the needs of involved individuals that include timely and transparent procedures for the investigation and analysis are necessary.

  • Provide a culture where staff can share their emotions and receive personal and professional reassurance.

Mixed: 10 doctors, nine nurses, two allied health professionalsQUALITATIVE
In depth semi-structured interviews
Second Victim
Van Gerven et al 44 2016BelgiumTo examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on doctors, nurses and midwives
  • Organisational cultures of support and respect reduce psychological impact of patient safety incidents. However, only when full support rather than partial support is given.

  • Organisational cultures that blame create a ‘devastating’ psychological impact on second victim.

  • When patients experience ‘severe harm’ doctors report higher retrospective psychological impact compared with nurses who report higher retrospective psychological impact when patient dies.

  • Leaders have a role in teaching others to investigate and debrief without blame and instead create performance improvement

  • Junior clinicians to be made aware of the topics by senior clinician coaches.

  • Regular non-confrontational peer review meetings should replace incident based meetings, providing clear information and acknowledging learning opportunities.

Mixed: 378 doctors, 1294 nurses, 83 midwivesQUANTITATIVE Self-report questionnaireSecond Victim
Van Gerven et al 45 2016BelgiumTo investigate the prevalence of healthcare professionals involved in patient safety incidents (PSI) and the relationships of involvement with and degree of harm with medication, alcohol, burnout, work-home interference and turnover intentions
  • Theoretically, involvement in PSI constitutes a resource loss (Conservation of Resources Theory). Resource loss invokes stress (eg, burnout) leading to further resource loss (eg, confidence loss, work-home interference).

  • Alcohol consumption, problematic medication use are coping strategies to counteract loss.

  • High quality of work and positive organisational commitment support the reduction in turnover intentions.

  • Critical Stress Incident Management (CSIM), psychological debriefing following PSI and support systems help second victims cope more effectively.

  • ‘No blame, No shame’ culture coupled with recognition of the role that system errors play in learning are helpful for second victims and prevent future errors.

Mixed: 1192 doctors, 4596 nursesQUANTITATIVE Self-report questionnaireSecond Victim