Second Victim Syndrome: A Joint Commission Nurse Shares Her Trauma | Joint Commission
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This blog shares experiences, case studies and news that add insight and value to the accreditation and certification journey.

Second Victim Syndrome: A Joint Commission Nurse Shares Her Trauma

Feb 07, 2018 | 1878 Views

In recent years, there’s been an increase in recognition of second victim syndrome, which describes mental trauma common to practitioners after a patient’s adverse health event. The Joint Commission has published a Quick Safety and recent guest blog examining the implications of second victim syndrome, both for clinicians and their patients. One of our own Joint Commission staff members reflects here on her own personal experience with second victim syndrome, years after realizing that her suffering was a common condition. 


One seemingly routine day as a surgical nurse changed the trajectory of my entire career. 

I was a nurse in the operating room (OR) suite with a clinician performing a cervical epidural steroid injection. While in post-op, the patient developed a spinal hematoma that led to permanent paralysis.  

The physicians wanted to transfer the patient to an acute care facility for neurosurgical intervention to try to minimize the paralysis. The patient was reluctant to accept the transfer recommendation. It was understandable as the patient walked into the facility and now was experiencing a life-altering event. It was too much for him to comprehend. The medical team ultimately agreed, but the delay probably impacted the severity of the outcome. 

It was later discovered that the patient had been taking a new anticoagulant that should have been discontinued days prior to the procedure. Since the patient completed consents and received instructions at his physician’s office prior to coming to our facility for the procedure, the pre-procedure screening did not catch this medication change. This was at a time when pre-procedure checklists were not utilized.  

Management’s Reaction

Days after the event, the director of nursing asked me to her office to discuss the patient safety event. She read the patient’s chart aloud and asked me what I remembered of the day and event.  

However, I was never asked how this incident may have impacted me or if I was able to continue with my duties. I was not provided any indication of next steps to expect. It was never discussed after that.  

I continued working with the same team, but the event was like an elephant in the room all the time. I kept wondering, “What did I do wrong? How did this happen?” 

Worsening Guilt 

I felt guilty and had doubts about my skills as a nurse. Following the incident, I found myself triple and quadruple checking everything I was doing, taking longer to complete tasks, hesitating to complete the most basic nursing functions.  

I grew skeptical of my co-workers. Could I trust them to do the right thing?  No one ever spoke about the event. If they did, it wasn’t public conversation. I had never been involved in an adverse event before, at least as far as I am aware. 

After a few months, I left the facility but remained in nursing. It never occurred to me to ask for any kind of emotional support. Had I received some counseling, I may have stayed in that position. 

Contextualizing Second Victim Syndrome  

It wasn’t until I had been working at The Joint Commission for a while that I met with a director who talked about the second victim experience. I was able to convey that learning about the science of patient safety, latent failures, and human factors helped me process the incident. I still think about the event, but I have a better understanding of how the system failed this patient. 

It is estimated that nearly half of health care providers could experience the impact as a second victim at least once in their career. Read more on appropriate supports that can help reduce stress on the clinician and prevent them from leaving the profession. 

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