Every Sentinel Event Has a Second Patient. They Are Back on Shift Tomorrow.

QA exists to protect the next patient. Done correctly, it also treats the one in uniform.

Somewhere tonight, a paramedic, EMT, nurse, or physician is awake at 2 a.m. replaying a call.

Something went wrong.

Maybe they made a mistake. Maybe they did not. Either way, the questions are the same.

Did I miss something? Could I have done something differently? What does everyone think of me now?

I know those questions because I have lived them.

About 15 years ago, a young boy came into my emergency department because his back was itching.

That was it. He was running up and down the hallway. His neurologic exam was normal. His strength, reflexes, sensation and gait were normal. I obtained X-rays, which were also normal. I sent him home.

The next day he was diagnosed with Ewing sarcoma of the spine. What he had described as itching was actually paresthesia.

Thankfully, he did well. He is an adult now, and I still keep in touch with his family.

But the hospital performed a root cause analysis of his case.

I was not invited.

Nobody asked me what I saw that night. Nobody asked why I made the decisions I made. Other people sat in a room and reviewed my care without the one person who had actually been standing in that room with the patient.

Eventually, I learned that some people on the committee defended my care and felt the workup had been appropriate.

I was grateful.

But looking back, I should not have had to be grateful that the right people happened to be sitting in the room.

And nobody ever sat down with me afterward and said, here is what we found, here is what we think happened.

So I carried it myself.

For years.

I have also made a real error.

In 2005, I gave a child ten times the medication dose I intended to give. I have spoken publicly about that mistake many times.

Those two cases were very different. In one, I made an error. In the other, I believe my clinical judgment was reasonable.

But emotionally, they had something in common.

I was left alone with both of them.

That experience has changed the way I think about quality assurance.

We usually think QA exists to protect patients. Find the error. Review the chart. Fix the protocol. Educate the clinician. Prevent it from happening again.

Of course it should do all of those things.

But there is another patient in the room.

The clinician.

The literature calls this the second victim. After a serious adverse event, clinicians can experience guilt, anxiety, loss of confidence, intrusive thoughts and fear about how their colleagues now see them.^1,2

EMS may be particularly unforgiving, because after the review is over, that clinician goes right back on the truck.

I saw this recently after a sentinel event at one of my agencies.

I will not share the details because they do not matter.

What matters is what happened when we brought the people involved into the room.

We talked about everything.

What happened. What decisions were made. What the system contributed. What could have been done differently. What needed to change.

Nobody minimized anything.

But nobody was looking for someone to blame, either.

And I watched the people in that room change.

The tension disappeared.

Then something happened I did not expect.

The clinicians closest to the event asked if they could help teach the rest of the department about what had happened.

That moment radically changed the way I think about QA.

And we decided not to leave that kind of experience to chance.

We have since put a formal QA policy in place that ensures this process happens. When a serious event occurs, the people involved have a voice, the case is reviewed fairly and promptly, the findings are shared with them, and support is part of the process. Not because someone happens to remember to do it, but because that is now how we do QA.

A good quality process does not just identify what went wrong.

It gives the people involved a voice.

It separates human error from reckless behavior.

It looks at the system instead of automatically blaming the person closest to the patient.

It tells the clinician what was found instead of leaving them wondering. The question stops being asked at two in the morning because it finally got answered at ten.

And when appropriate, it gives them the opportunity to turn one of the worst calls of their career into something that protects the next patient.

That last part matters more than it sounds. When researchers interviewed clinicians about their recovery after adverse events, several described getting involved in improvement work as the thing that let them enjoy the job again.²

I have spent much of my career trying to build systems that prevent someone else from making the medication error I made in 2005.

I could turn that experience into something.

But I could not build my way out of the other case.

What I needed then was not another technology.

I needed a room.

I needed someone to ask me what happened.

I needed to hear what the review concluded.

And I needed to know that one case did not define me as a physician.

It took me years to figure that out on my own.

Some clinicians never do.

They become quieter. They stop volunteering for difficult calls. They lose confidence. They transfer. Sometimes they leave the profession entirely.

We call it burnout without ever asking whether it started with one call that nobody helped them process.

QA absolutely exists to protect the next patient.

But if we do it correctly, it can also take care of the clinician who cared for the last one.

That boy with the itching back is a grown man now. His family and I still talk. They never once made me feel like I had failed them.

The silence afterward did that.

Fifteen years ago, nobody asked me what happened.

A few weeks ago, I watched a group of clinicians get asked that question, answer it honestly, and walk out of the room lighter than they walked in.

None of them are lying awake tonight wondering what their department thinks of them.

There were two patients in that room.

This time, we took care of both.

References

1. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-727.

2. 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(5):325-330.