Ending the Silence for Second Victims in Health Care

Abstract

I was a nurse in the operating room working with a health care provider administering an epidural block. After the procedure the patient developed a spinal hematoma and permanent paralysis. An investigation determined that the patient was taking a new anticoagulant that should have been discontinued days before the procedure. The consents and instructions for the procedure were done in the doctor's office, so the preprocedure screening at our facility did not catch this medication. In addition, the procedure was done before the initiation of checklists. My nurse manager discussed the error with me days after the event. This was the only time we spoke about it. I continued to work in the department, but I kept wondering, “What did I do wrong?” “How did this happen?” I felt so guilty about the event. 1 The Joint CommissionQuick Safety Issue 39: Supporting Second Victims. 2018https://www.jointcommission.org/issues/article.aspx?Article=kU05Lm5pzhA5MirdUIJfV617SJazGSVs%2bySZ7vKCm5g%3dDate accessed: July 14, 2018 Google Scholar Jacqueline Ross, PhD, RN, CPAN, Department of Patient Safety, The Doctors Company, Napa, CA