Leadership Pt. Safety Quality Risk

An Accountable or A Second Victim

In 1994, when I was an anesthesia intern, a bride and groom were admitted to the operating theater after a sudden road traffic accident during their celebration while they were going home. The attending consultant (my professor) tried his best to save them, but the bride passed away 15 minutes after arrival.

He turned to me and said that he had to leave and asked me to cover the service for the rest of the duty and call another consultant in case of need. I thought that he was escaping from the work.

My Professor: Dr. Ezz Al-Shazli

8 years later, I understood why he did that

In 2002, when I was dealing with a case of sudden cardiac arrest, the case was 19 years old female who had gone through a tonsillectomy procedure. I breathed a sigh of relief when the case was revived after an effective Cardio-Pulmonary Resuscitation (CPR), all vital signs became within the acceptable range in addition to spontaneous regular breathing. I met the patient family and reassured them.

An hour later, the monitor declared an alarm with a flat ECG, and the case passed away irrespective of the continuous attempts of CPR.

I was so distracted, couldn’t meet the family again and I told my colleagues to take charge.

After that I said what I had been told 8 years back from my professor; I have to leave, please cover me.

Over the years, I’ve never forgotten that case or the events of that day. Now, 16 years later, however, I changed my career, and it still haunts me.

This event was a turning point in my thinking and my life as a whole.

I am proud of the best decision I have ever made, the decision to change my career from treating patients to treating healthcare systems. 

I started to find the answers to many questions; why medical errors happen, why our patients are not satisfied, why all of us suffer, and why a lot of resources are utilized to produce a minimum outcome, …….

The answer of all those questions is that ” Every system is perfectly designed to get the results it gets”.  In looking at the total of our work, I realized that we are focusing on individual work rather than the whole system.

Treating diseased people is the main core of healthcare, but treating diseased healthcare systems is a priority.

Second Victim

Second Victims are “healthcare providers who are involved in an unanticipated adverse patient event, medical error and/or a patient related injury and become victimized in the sense that the provider is traumatized by the event.”

Second Victim is referring to the impact on the healthcare providers involved in a negative patient outcome- especially when there has been an error or the provider feels responsibility for the outcome.  These events may cause the provider to feel guilty, fearful, frustrated, anxious, depressed, demoralized and even suicidal

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Dr. Khalid Abulmajd

Healthcare Quality Consultant

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