In this presentation, we're going to talk about second victims. By now, you know that events happen in health care, and these events can have a significant impact on caregivers. I'm going to share a few cases with you to demonstrate just how these events can impact our caregivers. There is a story about a pharmacist, Eric Cropp, who was working at a hospital in Ohio, and he was the only pharmacist staffing with a pharmacy tech overnight, and a medication error was made on a patient regarding chemotherapy. And the chemotherapy, unfortunately, was administered to the patient and the patient died. Eric was not supported after the event was discovered. He was criminally charged and spent time in prison for involuntary manslaughter. You can watch this video on YouTube to just see how just it impacted his personal and professional life. Another story is about a nurse named Kimberly Hyatt, who was working in a hospital in Seattle. And Kimberly made a tenfold overdose on medication for a patient. The patient ended up dying a few days later -- not ever directly tied to the medication error -- but Kimberly went unsupported and was terminated from her job as a nurse. And seven months later, Kimberly decided to take her own life. Our very own story here at Johns Hopkins Hospital happened in 2001 on my unit, a pediatric unit here, where we had a patient by the name of Josie King, who was a baby that was admitted for severe burns related to a bathtub accident. Josie was making great progress and was transferred from the ICU to my unit, the intermediate care floor, where, after a sequence of failures to recognize and treat her deterioration, she coded and she died. You can imagine how that impacted all of the people that were taking care of her. As a matter of fact, in the year to follow, I watched several of those good people leave the unit, the organization, and the profession. These people can be defined as second victims. Second victims are defined as health care providers who are involved with a patient- related adverse event or medical error and, as a result, experience emotional and sometimes physical distress. Second victims often feel personally responsible for the outcome -- feel as though they have failed the patient and question their knowledge and their competence. And so I ask you, do you have to be involved in a medical error or adverse event to have these feelings? My guess is that your answer would be no. There are many events that take place in health care that can cause us to feel this way. However, mistakes are one of the most significant reasons that we could feel responsible, or like we failed, or like we're incompetent. And some of the other stress responses that we might have is horror and fear, remorse, anger, guilt, isolation, no place to hide, or doubt -- feelings of incompetence where we might think we're not good enough or we question our professional career choice. So why is it that we keep coming back to work in this complex environment? Well, the trauma resilience model tells us that most of us are built with a resilient zone and for each of us it's different. But in this resilient zone, we can flex and adapt to stress that happens. And so we can manage the stress and be our best self. However, sometimes we get knocked out of this resilient zone. And it could be one event or it could be an accumulation of events, and we could get stuck on high, or hyper-arousal or anxiety, or we can get stuck on low, where we're feeling depressed or isolated. And when we're out of our resilient zone, we cannot be our best self, not personally or professionally. There's a cost associated with this, as well. When we are not our best self, it may cost the organization money. So if a nurse decides that he or she is going to leave the organization, costs may be up to $64,000, and more recent reports say possibly up to $100,000. To replace a physician is way more than that: up to $630,000. And we know that events are going to continue to happen because of the complex environment that we work in. As of right now, medical error is the third leading cause of death in the United States. That's an estimated 400,000 people that die a year from medical error, costing us $19.5 billion. And that's a report from 2008. So, if our staff are feeling stressed and they are not supported, this has an impact on them as an individual. These might be the people who don't want to come to work or maybe they come to work and they have a bad attitude. And then they have an effect on their team, and people on that unit don't want to stay there. And then you have a result of turnover, and when you have turnover, you have an unsafe care environment where patients aren't getting high quality care. And then we have dissatisfied patients who are at risk for harm because of the environment they are being cared for in. And when we have dissatisfied patients, they tell everybody about their dissatisfied experience, and then the institution has a bad reputation. And so our leadership becomes stressed. And so you can see how it has an impact on an individual, on a team, and on an organization as a whole. Sue Scott from the University of Missouri tells us there are six stages of recovery. Stage one is chaos and accident response, where the caregiver is asking themselves what happened, and they're in shock. Stage two is intrusive reflections, where the caregiver may be replaying the event over and over again. Stage three is restoring personal integrity, where the caregiver might be asking themselves, who can I talk to? What are people saying about me? Stage four is during the inquisition, where the traumatized caregiver might have to answer questions about the event. And stage five is obtaining emotional first aid, which we're going to talk about in our next presentation. What is it? Where do you get it? And how can it impact our traumatized caregivers?