Hello, and welcome to the Society of Critical Care Medicine Anniversary Congress presented virtually. Our topic today is called Bouncing Back, the Struggle of the Second Victim Syndrome. My name's Judy Jacoby, a former critical care pharmacist and senior consultant with VSUNT, and I'll be your moderator today. I have no disclosures for conflict of interest on this topic. What we'll be talking about is to define the second victim syndrome, discuss risk factors associated with those situations that clinicians may find themselves in, and talk about strategies both at the health system level and at the practitioner level to help mitigate some of the problems. I'm thrilled to have two well-established speakers on this topic. First we'll have Brian Flaherty from the University of Utah. He's an assistant professor in the Division of Critical Care at the University of Utah Primary Children's Hospital, and is involved in quality improvement systems in the ICU and quality improvement education for resident and fellow trainees. His research interest is in resource utilization and improving the value of care in the pediatric ICU. Jennifer Wertham is a postdoc fellow at the Tennessee Valley Healthcare System. She's a graduate of Vanderbilt University's School of Nursing PhD program, and is currently, as I said, a postdoc fellow in the VA Quality Scholar Program. She has broad experience in nursing and healthcare leadership, and her research interests focus on organizational concerns including patient safety, systems, and the hospital workforce. Just to start us off, of course, medical errors are common. There are common events that we sometimes track formally, and others that perhaps less formally depending upon your organization, with a whole host of contributing factors that I think are well known to this audience, certainly many of which have been highly exacerbated in a COVID-era staffing crisis and pandemic. Just to give you a quick definition of the second victim syndrome, we know that our patients are indeed exposed to preventable harm. We've studied for years since the original assessment from the Institute of Medicine to AIRS-Human that these adverse events are often related to a system-level problem. But certainly, the patients or their family may undergo harm, and they would be the first victim. The second victim are caregivers and staff who could suffer complex psychological harm after involvement in an error. I think everyone listening who has some role at the bedside is going to have had elements of concern about, what was my role? Did I do something wrong? There may be varying levels of guilt. I know it's been highly exacerbated in the COVID-era. At Indiana University Health, where I practiced, we made a very public mistake with administration of high-concentration heparin to neonates, with devastating results. Something we disclosed publicly, and while I wasn't involved, certainly as a department, we felt badly about the situation, and certainly the individual pharmacy personnel who were involved suffered greatly, although did not lose their jobs, as well as the nurses involved suffered greatly in terms of how this was handled. We've all got that firsthand experience, and so now I'm really pleased to have Dr. Flaherty talk further about some of the issues associated with the second victim syndrome. Thank you, Judy, for that introduction. As she mentioned, I'm a pediatric intensivist at Primary Children's Hospital in Salt Lake City and work in the Division of Critical Care at the University of Utah. I appreciate the opportunity from the Society of Critical Care Medicine to come and speak and raise awareness about an issue that many of us have experienced or will experience in our future careers. To begin with, I have no financial disclosures. My objectives for my portion of the presentation are really to highlight what the second victim syndrome is in terms of somewhat of a formal definition, as well as what the experience of someone going through the process of being a second victim is and what happens to them on the other side, so to speak. To start with, to develop a definition of what the second victim syndrome is, I actually want to go way back in the literature before the term itself had been coined, but just to descriptions of what healthcare providers went through after an error involving a patient. The earliest description of this I could find was back in the mid-'80s, and it was actually written by a family practice physician in northern Minnesota. Essentially, what was a little bit of an op-ed piece for the New England Journal, he described a series of errors and events with patients that had stuck with him throughout his career. He described that after some of these events, he would get feelings of guilt and anger. He had this desire to discover what had gone wrong in his care of his patients. He concluded his article by really shedding light on the idea that medicine and those who practice it are not perfect, yet many of us, especially at the time, strived for perfection and when it wasn't met, it was buried and all the feelings with it were buried. He felt this was probably not the right thing and certainly not a healthy thing for healthcare workers to do. During this piece, there were assorted opinion pieces from physicians, nurses, and hospital administrators, all kind of highlighting this idea that when a patient is hurt by the medical system, they're not the only one who's hurt. Those who provide a care also have symptoms and feelings associated with it, but it wasn't until 2000 that the term second victim syndrome was actually coined. It was written by Albert Wu, who is one of the thought leaders in this area and works at Johns Hopkins. In an article, he talked once again about these feelings, this sickening realization you have after a bad mistake has occurred. The fact that the event often replays itself over and over in your mind as you're trying to figure out what you could have done differently and to the point where these events can lead you to question your own competency and have fear about what happens when others discover the mistake. Following this article, the research into second victim syndrome really kind of took off and with it, there was development of formal definitions. The one I want to share with you was developed by a group working at University of Missouri, and in kind of a similar paper they wrote, they defined the second victim as a healthcare provider who was involved in an unanticipated adverse patient event, and they're traumatized by that event. They may feel like they have failed their patient. They find themselves second guessing their skills and their knowledge base. So as we move forward through our talk, I'm going to share with you kind of some highlights from the literature that describe what does people go through after an event with a patient, but I want to stop for one moment before we dive a little bit into the literature and kind of think of just some high-level things about what a second victim is and what the syndrome is. So it's certainly a feeling or a series of feelings that are experienced by healthcare providers, but it's also a process. It's not a one-time thing. It's a series of emotional and cognitive events that someone goes through. And finally, a second victim is a person, and it's not just any person. It's the people that we work with and care about on a day-to-day basis, and Jennifer is going to touch a little bit more on this in her portion of the talk. So to move forward a little bit about what a second victim goes through, this is another portion of the article by Susan Scott, who penned the definition that we're using, and they did qualitative structured interviews with 31 individuals at their medical center who had been involved in a patient harm event, and their goal was really just to understand what people were feeling and how they moved through this process after an event. And so in their study, they kind of divided the symptoms into physical symptoms and psychosocial symptoms. The physical symptoms included fatigue, sleep disturbance. There were sympathetic changes with heart rate and blood pressure elevation. And then on the psychosocial side, feelings of frustration, decreased satisfaction in their job, feelings of anger and guilt, and even some more extreme feelings of grief, remorse, and depression after what had gone on. Taking a slightly larger look to understand what happens to caregivers after an event, there was a large study that surveyed caregivers throughout Canada, Seattle, and St. Louis. In the end, the study looked at 3,000 respondents, and they were representing the fields of surgery, pediatric, family medicine, and internal medicine. They were aiming to look at the specific prevalence of certain feelings or symptoms after a medical error. And in the graphic I'm displaying here, which is their main results, they broke apart the type of error from a near miss all the way to a serious event, something that would be a patient death or permanent harm. And what they found was feelings of anxiety or worry about future errors were extremely common, decreased job satisfaction in a third to a half of the respondents, and once again, issues with sleeplessness or sleep disturbance. They also found that as the severity of the error increased, the prevalence of all of these symptoms tended to increase. Just recently, there's been a large meta-analysis further trying to categorize what symptoms are involved in this. This meta-analysis looked at 18 different studies, involved over 11,000 subjects across all different specialties as well as roles within the hospital. So physicians, trainees, nurses, respiratory therapists, patient care technicians. And as you've kind of seen from the previous two slides, there's kind of a theme here. Anxiety and concern for the future and the ability to provide care is a very common symptom. In this study, troubling and intrusive memories were the most common thing. The issues with anger towards oneself or guilt and those kind of more severe symptoms of depressive symptoms, loss of kind of overall daily quality of life were there. So those are kind of three successive studies moving from a single center kind of qualitative look all the way to now the most recent evidence of a meta-analysis, and it's a lot of things to try and take in about what this second victim syndrome can look like. I want to take just a moment to kind of display it out and simplify or summarize things. And really it's a series of psychological, physical, and behavioral cognitive symptoms where things like depressed mood, shame, and anger are common. Physically having trouble with sleep and physically feeling yourself kind of alert and wired more at work. And then cognitively having issues with your own confidence. There are reports of issues with potential of alcohol and drug use. Now, as I've been going through some of these symptoms individually, I'm sure some of the audience have kind of been adding them up in their heads and thinking some of these people are going through some true psychiatric diagnosis and those of you thinking that are absolutely correct. As you start adding these symptoms together, you actually start realizing second victim syndrome can have components of post-traumatic stress disorder, depression, burnout, and tremendous decrease in quality of life. There's not great research and literature right now to describe after an event how many people go on to develop true clinical depression or burnout or PTSD, but there are certainly reports of its association with errors in patient care. I want to change gears just a little bit and move from kind of these individual symptoms building up to some of these kind of more ominous diagnoses and talk a little bit about the process over time of what a care provider goes through after a patient harm event. And so we're returning again to this paper by Susan Scott from 2009, where they did these qualitative interviews. Kind of the most impressive results was kind of this six-step model of how someone understands and moves on after an error. So the six steps, the model was developed by Susan Scott and her group. I actually took this graphic from a separate paper by Mitzman et al., which was published just over a year ago. And so in the immediate aftermath of a patient harm event, kind of this first step known as chaos and accident response is just this realization that something bad has happened to the patient. And all the effort to go in to figure out exactly what has happened, check on the patient and stabilize them. Once kind of the initial alarm has died down and the practitioners involved have had time to think about it and realize that an error has happened, we get to the second step of intrusive reflections where people are replaying the event over and over, trying to understand how they did what they did, what they could have done differently. And after that, you get to a third stage, which is kind of the first part of coping and kind of stabilizing. And it's been termed restoring integrity. And this is the first attempts by the second victim to reach out to those around them, to start feeling that they are okay, that they can still function and do what they do and that they're not bad, for lack of a better term. Unfortunately, the way this progression works, you kind of get to this third phase relatively quickly and then in step four or stage four, kind of the healthcare system starts to catch up and there is, depending on what the event was and the degree of harm, kind of a system level investigation of what went on. And so the second victim who was just starting to kind of pull out of what is essentially a series of negative feelings is kind of thrown back in it. And they start worrying about, you know, is this something where I might lose my job? Am I going to lose my license? What is going on? And so for second victims who unfortunately sometimes have to endure that, the step after that is kind of more true emotional first aid and really going towards longitudinal healing. So step three is kind of this quick, put your finger over the hole in the dams type step. And step five is a little bit more kind of permanent repair for the second victim. And this is where they're going to be more formally reaching out to their colleagues. And as Jennifer will talk about, potentially the system reaching out to them to make sure that they're supported the best they can. The sixth and final stage that Scott and her group identified, they term moving on. And essentially this is a try fork in the road, if you will, where some will go on and return to their jobs and thrive. These might be people who are able to kind of understand their role in a system and see that yes, they may have made an error, but there are bigger system things and that everything is not on them. And they're able to kind of practice at the level they were before. This also includes a group of people who become very interested in patient quality and safety and become leaders in their unit, really working to make sure what happened to their patients and their feelings doesn't happen to others. There's a second group who kind of stays in the same role, but they're never quite the same and their term surviving. And then there's a third group that as a result of what they've been through, they don't want to ever go through it again. And whether it's just moving to a different unit or a different hospital to escape what they feel is the shame or guilt from the event, or truly leaving their profession where they will never be at risk to feel something like that again, those are the folks in that group. I'm going to spend my last couple of slides talking a little bit about these surviving and dropping out groups. An interesting study that was published a few years ago now looked at anesthesiologists who had a negative event in the OR, which was an unexpected death, a heart attack or stroke or other severe patient event. And this was a survey study that had 700 respondents from the US. And one of the things that the survey asked was, how long before you felt you were emotionally back to normal after the event? And so within a week to a month, a bulk of the respondents were emotionally back to where they were. They were getting back towards thriving. But what was really interesting for me was there's a huge number of practitioners, almost a third who at six months aren't emotionally back to where they want to be. And there's some who more than a year out aren't there. And there's almost 20% who feel like they've never really recovered. This is that group that is just kind of surviving and hanging on. There's not a lot of great data from other specialties or fields that describe it so nicely on what the distribution of potential for going back to thriving towards just the surviving group. But just the fact that even in just one specialty, 20% almost of people are never really getting back to where they were is a pretty concerning idea. And then there's that group that drops out and what happens to them. So the last study I'm going to share with you was published back in 2008, and it was a convenient sample survey of health care workers. And it was a broad spectrum of fields, so physicians, nurses, respiratory therapists who had left their position. And so a good number, so almost a third essentially left the medical field, the active medical field. They were in a non-clinical position. They became consultants, or they had taken something entirely out of health care. And then about a third or so actually left to a different unit or department or hospital. So didn't necessarily leave the bedside, but there was something they were trying to escape. And that's how they were able to kind of move on. So with that, I'm going to draw to a close with my portion, and I'm going to hand it over to Jennifer, who has some really interesting things to talk about in terms of what systems do to recognize and help support practitioners going through this. Thank you for your time. So my name is Jennifer Werthmann. I am currently a health care quality fellow in the VA Quality Scholars Program at the Tennessee Valley Health Care System in Nashville, Tennessee. I have a special interest in second victim syndrome. I've worked for a number of years in both nursing and nursing leadership and have experience on both the clinical and ultimately administrative side with some of the challenges that some of our providers face as second victims. I'm also involved in a work group at the VA where we're looking at second victim and some of the resources that support second victims within our system. I'm going to continue talking with this presentation about second victim syndrome and some of the resources, as mentioned, that support clinicians who might be experiencing symptoms of second victim after a critical event. So I have no formal financial disclosures to note, but I would like to acknowledge that this work is supported by the Office of Academic Affiliations, Department of Veterans Affairs, the VA National Quality Scholars Program, and with use of the facilities at the VA Tennessee Valley Health Care System in Nashville, Tennessee. The views expressed in this presentation are those of myself alone and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs or the United States government. So we have previously defined second victim syndrome and thinking about the challenges that face the second victim and how it's defined, when we're looking to build programs, we're looking really to build programs that support these individuals who are feeling personally responsible that they may have failed their patients and they may be beginning to second guess their clinical skills. We also know, as Brian mentioned, that recovering from second victim really occurs on a continuum ranging from that initial recognition to that midpoint of searching for acceptance through moving on. So another goal of programmatic development would be to help that clinician successfully reach that sixth stage of moving on, but with that outcome of thriving within that step, going beyond that dropout or survival phase. So as a reminder, these are our objectives. We're going to focus on some of the prevention and intervention strategies to support second victims. So how do we do this? The literature actually offers us a few resources about frameworks, different program examples and structures that are helpful to creating second victim support programs. To start, actually, the Joint Commission issued a quick safety newsletter in 2018 that described second victim syndrome and the extreme importance of supporting clinicians who may be experiencing second victim syndrome symptoms. They specifically tie the support of clinicians to the support of patient safety. They state that really by supporting clinicians who may be suffering from second victim syndrome, other patients are protected from that domino effect that adverse events can have on provider performance. Specifically, the brief indicated that there are very specific certain safety actions that are noted on this slide to support second victims of an event. So it's things like engaging the entire team in the debrief and event, providing guidance on how team members can support each other, maybe including second victim support programs that might bolster currently applicable employee assistant programs that your hospitals may already have. While the Joint Commission brief identified the potential need for more formal second victim support programs, there are second victim resources that probably already exist within your organizations, although they can vary significantly. They can exist simply as support from individual unit leadership or organizational leadership to faculty assistance programs, to employee assistance programs, clergy, social workers, counselors, to these more formal second victim support programs that are built and potentially designed from standardized frameworks in crisis management. So one example of a framework that a more formal second victim support program might use is the Critical Incident Stress Management Framework. Just as second victim syndrome recovery is a comprehensive process, the Critical Incident Stress Management Framework is a seven-step comprehensive process for supporting individuals or larger communities after times of crisis. You can see that it ranges, again, from a preparation stage or pre-crisis to that midpoint of diffusing and debriefing and counseling to the post-stages of follow-up and management. Another model that is seen in the literature a lot is the Scott three-tiered model created by Dr. Susan Scott and colleagues at the University of Missouri Health Care. This model consists of three tiers that range from basic emotional aid to outside support where the clinician needs can be provided by the second victim team. Tier one really focuses on that basic emotional first aid at the local level, making sure everybody is okay. Tier two focuses on the guidance and support for the identified second victim by peer-trained supporters. And tier three recognizes that there may be needs outside of what a peer supporter can actually provide, like counseling or legal services, and can aid in the fast track to referral to those resources. To get into some specific examples of programs that are actually seen in the literature, we're going to start with the 4U program that was developed at the University of Missouri. It's a fairly well-known program that is seen in the literature a lot based on that described Scott three-tiered model. The program is seen frequently in the literature as a standalone program, but also as a model that organizations can use to build programs at their own sites. Key components of this program, and you'll see these in a lot of the different programs that we'll talk about, include the use of this three-tiered model, interprofessional 24-7 peer support, and then continued learning for interprofessional members who act as peer supporters. Reportedly, they meet actually monthly to debrief and continue training through a peer mentoring process. The second program we'll talk about is the You Matter program founded at the Nationwide Children's Hospital in Columbus, Ohio. This is one example of a program that is actually based on that University of Missouri 4U program. Nationwide Children's collaborated with the University of Missouri to create a program framework and establish this training for peer supporters. Started as a pilot program in 2013 and then rolled out hospital-wide about five years ago in 2015. Key characteristics, again, of this program include the use of that Scott three-tiered model, using, again, trained peer supporters to provide frontline support with capability to escalate as needed in that 24-7 accessibility. The Resilience and Stressful Events program is found at the Johns Hopkins Hospital in Baltimore, Maryland. It's another example of a support program for second victims. Key characteristics, once again, include that it's accessible 24-7. Support is provided by a group of interprofessional peers. And then what you'll see with some of these programs is some of the second victim programs actually operate independently and some exist to complement those existing operational support resources that I previously mentioned. So one very important part of understanding second victim support services, aside from identifying whether they exist in the institution at all, is really understanding how effective any offered resources may be to employees who are suffering symptoms of second victim. Returning to the brief issued by the Joint Commission, there are a few noted components that they recommend are included in all second victim programs in future program development. And these things are listed here on this slide, including things like strong patient safety culture, organizational buy-in, having executive champions, using an educational campaign across your hospital to reduce stigma and bias, providing some sort of pure or procedural guidance for first responders, and using evidence-based guidelines. Also, things include identifying your confidentiality protections about what's discussed as a result of an event, surveying users to determine effectiveness, very important in program development, measuring and tracking utilization, and then measuring effectiveness of your program and revising as needed. There is a formal program evaluation tool that is seen in the literature that is actually a validated measure. It's called here the Second Victim Experience and Support Tool. The purpose of this instrument is to really help to evaluate the second victim experiences and the quality of the programs and resources that are offered. This tool is actually, as I mentioned, a validated survey measure that's made up of 29 questions representing seven different dimensions and two specific outcome variables. The seven dimensions measured by this tool are seen here, along with two very important outcome measures that have a significant impact on your hospital teams, patient safety and quality of care delivery. You have turnover intention and absenteeism. So two very, very big things that have a lot to do with the support that might be seen after a second victim event. Despite the availability of different resources and frameworks to build them, there are some noted barriers to program use that are very, very important. A 2017 qualitative study titled Do Hospitals Support Second Victims? Collective Insights from Patient Safety Leaders in Maryland used a series of semi-structured and structured qualitative interviews with patient safety representatives at 38 hospitals in Maryland. The goal was to describe the desirability of second victim resources and to identify different support programs that existed within these institutions. The authors noted a number of barriers, with the top three being taking time away from work, doubts about confidentiality about what was discussed, and then concerns about things that were discussed or events ending up on the permanent employee record. Other barriers included ineffective support, just negative judgment from colleagues, and then stigma associated with accessing different services. So there are existing programs and resources as well as barriers, and it's very important, too, to think then who is at risk. When we think about second victim syndrome, we might be inclined to say, you know, I'm not at risk. It's not going to happen to me. However, as we know, providers are the largest member of the healthcare workforce within hospitals, and we're placed at the sharp end of patient care every day. So while this is not a comprehensive list, the majority of people who are working in patient care is at risk of suffering second victim syndrome. What the literature shows is it's something like a 10 to 40 percent prevalence among healthcare professionals, inpatient, outpatient, trainees. It's really anyone, everyone that are on that team. That being said, there is the potential for certain areas of the hospital to be higher clinical risk areas than others. In a study, a 2017 study titled The Deployment of an Institution-Wide Program, the authors actually describe the deployment of an institution-wide program that I previously mentioned at Nationwide Children's. In their review, they identified high-risk clinical areas being things like the emergency department, pediatric intensive care unit, cardiothoracic intensive care unit, pharmacy, with LPNs and RNs having the highest number of program encounters. There are also examples of publicly reported cases in the public domain in high-risk intensive care units. One such event was in the cardiac intensive care unit at Seattle Children's. Unfortunately, this was a medication error where 1.4 grams versus 140 milligrams of calcium chloride was administered to an eight-month-old child, had very sad, very negative consequences for both the child and the nurse involved in that case. ICUs as high-risk areas for second victims make sense if you start to look at the literature with regard to medication errors. There isn't time to discuss adverse drug events and medication safety in depth here, but just as an example, a 2015 article published in Nursing Critical Care indicated that ICU patients are just generally at higher risk for medical errors due to things like patient acuity, polypharmacy, altered pharmacokinetics, and increased length of stay. So hopefully this presentation has supported the idea that healthcare providers working in our critical care areas may be at higher risk of suffering from second victim syndrome. We really work hard every day to ensure that our healthcare delivery is safe and effective. However, medical errors will likely always be part of our work just due to human fallibility and potential for error. The 2017 Clinical Practice Guidelines for Safe Medication Use in the ICU published in Critical Care Medicine state in the very first sentence that medication errors and adverse drug events are a common and significant concern in the ICU. So it's really up to us as clinical peers, colleagues, and leaders within our organizations to advocate for the adoption of second victim support resources and networks to help protect our patients and our healthcare providers that may be involved in any kind of medical event or other traumatic event. Thank you. All right, well, thank you for those wonderful presentations. Certainly have outlined the structure and a bit of the science to give all of you an understanding of the potential solutions and issues associated with the second victim syndrome. For those of you listening to this, I'd like you to use the chat room function to ask your questions while we go on to discuss really some of the heart of some of this and perhaps flesh it out and in terms of how you as an individual can perhaps make a difference in your unit. So Dr. Werthmann, I'm going to start with you. And you've talked about critical incident planning and for any emergency, obviously the more you can plan in advance, the better the response is going to be. And clearly there are resources and structure out there, but I don't have a sense of how much hospitals have really focused on this and whether this is a priority to have in place. Do you have a sense of whether this is a common thing for hospitals to have in place or should our audience go back and start to ask questions? Certainly. Well, I can certainly only speak to what is available in literature, but I think that given the fact that this is a relatively new topic, just within the last 20 years or so, as Brian mentioned, the specific definition was coined in I think the year 2000. I think that it's still in development at a lot of institutions. I think that with the pandemic that we've had this year, that certainly this is something that is becoming much more of a priority in figuring out how to support not just clinicians that are involved in medical errors, but maybe involved in traumatic events and supporting the mental health and wellness of our employees. But I do think that it is still a relatively new topic. And so we might not see the types of formal structured programs that you might see at some other hospitals, but I do think that there are resources, like I mentioned, employee assistance and some of those other resources that absolutely can be utilized. You know, and as I think about, you know, Schwartz Rounds who, you know, certainly aren't as widespread as another vehicle to kind of get some of these issues out and discuss them and, you know, kind of remind people that these things go, you know, have such an important system level relationship. You know, I think as clinicians, we ought to be asking a lot of questions actually. So Dr. Flaherty, when you think about clinicians and the fact that there's a process and a progression that, you know, a very important component is restoring integrity in the, you know, the third phase and, you know, moving through those support systems, you know, in a COVID world right now, do clinicians even have the luxury of that time? And how can you encourage people to find a way to take that time or get support if they're not getting it from their institution? You know, that's a great question. Certainly the restrictions on distancing and actually being in a room with someone now, I think make it a lot harder. And there's certainly some literature out there from second victims when they're asked, you know, what did you need? What really helped you? And a lot of it is just, you know, the ability to talk to someone who's in a similar position to you. So people who understand what your unit is like, what you go through and can help remind you that, no, you are a good clinician and, you know, this happens. You're not the only one that can be the victim of a medical error. And so, you know, reflecting on, you know, how do we do things in the COVID era now? I think it becomes especially important for groups of clinicians to develop ways to interact kind of outside of work that are, you know, essentially online like this. So I'm part of a group where, you know, every Tuesday we have a Zoom call and the idea is not to actually talk about work or things going on in our unit. It's just kind of a social check-in so that we're keeping that social network intact. I think part of that lack of face-to-face contact, it's really hard to read how people are doing. And I think in times like this, a little bit more of the onus goes on to kind of the more senior people or leadership people within a unit when an event happens to be a little bit more proactive about reaching out and checking up and seeing how people are doing. I definitely worry that with some potentially overwhelming hospital census complexity of patients that as a, you know, a community of critical care providers we're at a little bit more risk for some events. And so I think, I hope that we don't have a rash of second victims that go unrecognized and unhelped, but just the situation kind of sets us up for it if people aren't a little bit more proactive. Absolutely. Jenny, any strategies that you've had in your unit to either allow people to kind of share experiences or, you know, give them a vehicle to open up to others a little bit? Because usually there's a lot of secrecy associated with an error or an adverse event. Maybe it'll be a little bit more public after a root cause analysis or something like that. But how have you engaged coworkers or your staff to try and draw them out and really hear where their concerns are? I think Dr. Flaherty is absolutely correct. It is really having that peer support available to allow clinicians to discuss events and having that person. And that's reflected in the literature too in a lot of the different program development. It's just having that person who is able to empathize with your situation, that they are in a very similar role as you. And as a nursing leader, not necessarily having your leadership come down and say, it's going to be okay. But while that's helpful, having someone who is, it's a peer-to-peer contact in a peer-to-peer network to be able to say, I understand, I may have been there myself, but just that they're able to really walk through that process with the person who may have been involved in that medical error. But that peer support is just so important and something that we've used a lot. How do you feel like people ought to interact with social media or do you have any advice for somebody who perhaps is concerned with their situation after an error and feel like the second victim? Do you encourage them to stay away from social media? Obviously, people are less than supportive when it comes to some of the social media platforms on activities like this. Can it be used beneficially or is it something best avoided? And that's for either of you. Oh, Judy, that's a great question. And I will admit that by age, I am technically a millennial, but I call myself a bad millennial and I don't participate in a lot of social media. And kind of like you mentioned, once things get put out there, they become kind of permanent, anyone can see them and anyone can comment on them without necessarily knowing all the details of what really happened. And so kind of my, I guess, personal bias would be, social media may not be the best outlet. Now, with that said, in the COVID era, if someone who is much more social media savvy than me and has really built up their support network through some of those platforms, maybe discussing certain aspects of things or as a way to find people to reach out to in another medium, that might be a beneficial thing. But like I said, my bias is kind of, I'm not a super tech savvy person to begin with, so I would shy away from it. I agree. I agree with those comments. I think that there's a permanence with social media that I think we sometimes take for granted that once it's out there, it's pretty much out there forever. So you need to make sure that what you're putting out there, you're okay with having out there forever. So I think that social media can certainly be beneficial, but when we're talking about traumatic events or errors that occur in an institution, there are certainly policies and things like that about engaging in social media at individual institutions that I think clinicians and providers need to be aware of. But I'm sort of the same way. I tend to shy away from social media myself, aside from just professional use of social media, not necessarily for discussing clinical events. And obviously it never should be used for an individual patient event. And even on Twitter, people have to be pretty careful about not getting too explicit about the interesting thing they saw yesterday, but yeah, I just think there's probably a lot more downside than positives that can come from getting heavily involved in social media. Maybe best to just walk away for a period of time. So as you were talking about all the symptoms, Brian, in terms of what people experience, you kind of listed PTSD as one of the elements, but honestly, when you look at the spectrum, this is a trauma that an individual has gone through and many of the physical as well as psychological aspects, certainly go along with that. Do you think there's anything that we've learned, and obviously we don't know enough about how best to treat PTSD, but are there some other things that we could take from the PTSD literature to help us do a better job about treating or supporting an individual? Yeah, that's a great question. And so a lot of the research and kind of that intersection between PTSD and second victim syndrome is looking at kind of the commonality in symptoms and the idea that with PTSD, there's some type of kind of physical emotional trauma that kind of sets the process in motion. And then on the second victim syndrome, there is the very real harm to a patient, but there has not been a ton of work looking at, can the treatment modalities, whether medication or kind of therapy techniques necessarily be applied to those who are going through the second victim syndrome? I think a piece of that is, like you said, it's a spectrum. So of all the people that are undergoing kind of the stress of the second victim syndrome, how many actually rise to the level where it would meet the diagnosis of PTSD? So it's a great question. I certainly think some of the kind of counseling and therapy techniques from PTSD are probably things that have a role in second victim syndrome. I mean, certainly as Jennifer talks about, having access to kind of professional counseling and EAP programs is already starting to kind of shunt those with the most extreme symptoms and experiences towards that. Do either of you have any advice, probably on an individual level, but certainly errors occur that may or may not be disclosed. That others may or may not be aware that there's even been an incident, but the health professional walks away with that residual. And so I can imagine that it would be very difficult for them to seek help in a situation, or perhaps more difficult in a situation where they think nobody else knows about it. What kind of strategies might an individual consider if they're in that situation where, as you pointed out, gosh, if I bring this up, am I gonna lose my job? But honestly, recognizing that if they don't bring it up, they'll never get the support that they potentially need. And any strategies for how best that, an individual actually could start. And obviously the institution's response hopefully would be supportive. That's a tough scenario, especially the type of thing where I guess you could kind of say a silent error or an occult error where maybe only the person that was involved in it knew about it. It becomes really tough. And I think from a system standpoint, it's something where you can't be reactive, that you have to be a very proactive system where you have created an environment where people feel that it is safe to disclose errors, which I think is something that is really difficult to create because it involves both mechanisms at a system level to ensure that people are treated fairly and helped, but also the culture of the people in a unit, in and of itself where it's more of friends. And when you are comfortable in a situation like that, I think you're able to disclose and get the help that you need. I think if someone's in a system where they've seen, what they view as kind of negative outcomes for people who have disclosed errors, or maybe the system has an okay apparatus set up, but the people that are around them, they perceive whether true or not are not gonna look favorably on them, it's gonna be really hard for them. So I think it's something that both at kind of the manager and system level, you have to cultivate a process that protects people, makes them feel safe. And then I think at an individual level, when you hear about errors, you have to be very open and understanding to what's going on, so that in the future, if there ever is one of these silent errors, the people that work around you have seen a positive response and are safe coming out with it. It really comes down to that culture of safety and how an organization has fostered that. When there is a big event, obviously it tests whether they can walk the walk versus just lip service to how they're gonna handle an error. And obviously an individual circumstance and employment and all that comes down to a lot of the specifics. But again, I think for those in the audience listening, certainly if you have thoughts on these, we'd love to see it in the chat room. But I think it's, again, something that we ought to be asking questions in our individual settings to make sure that people know that something like an employee assistance program or talking to your clergy, if your hospital has it, maybe outlets that are available. But really understanding that structure is I think gonna be an important part of being able to support our coworkers. So, it's interesting when you talk about the reaction from others. Gosh, over the years where there's been an error, I feel like more people are gonna be supportive. And you hear comments like, oh, I've come close to that, or there are near misses. I'm not surprised that this happened because this, this, and this has happened repeatedly. How can we get people to, again, be a little bit more proactive in speaking up about situations that, you know, the consistent near misses. And, you know, nobody's gonna have time to report any of this stuff in a voluntary reporting system now if you're overwhelmed by COVID and, you know, barely can get through your day. And reporting was never good even when people had reasonable staff to patient ratios. How, you know, have you done anything in your specific institutions to try and, again, get some debrief over situations or potential problems that are occurring? And, you know, at first in COVID, we got by doing whatever we could to get by. But, you know, in terms of what are some things that proactively an organization could do to try and draw out concerns from their staff and perhaps head off some potential errors? I think that is something that certainly involves the organizational culture and how that exists, just whether your organizations are supportive of a just culture or whether they're on a kind of a different trajectory. I think it, you know, having leadership, having an open door policy, having the ability for any employee to really do that stop the line type thinking where if there's a safety event, they just say, we gotta stop. And really having that open communication to make sure that when there are safety events or potential safety events that might be being recognized that we're taking that feedback from everyone that works in the institution, everyone on the team, whether they work directly with the patient or not, because everyone can be involved in understanding how systems work and how we can improve systems and safety and organizational culture. I feel like if, you know, if you have a medication safety officer in your institution, it's probably more important than ever for them to be out interviewing people in, you know, some of these high risk areas to, you know, really help draw some of that out as well. And, you know, where people just might not have even had the bandwidth to, you know, reflect and go, oh boy, that's a really scary thing that we're doing. Obviously being proactive about drawing out some of those conversations and observations is gonna be really essential. Any other, as we're finishing up, any other comments or points that either of you would like to emphasize or perhaps a call to action to organizations, health systems, individuals that, you know, they can really do and follow up to help influence the culture around them and certainly the circumstance around them and perhaps support their coworkers. I think the only thing that I'll say is I'm very happy that this is getting a lot more attention in recent years because the health and safety and health and wellness of our employees and our providers and clinicians is just so important and has just such a significant impact on patient safety and patient outcomes. And it's something that it's wonderful that it is getting attention to have this program develop, programmatic develop, programmatic development, excuse me, in recent years to really focus on employee health and wellness. Brian, any other thoughts? Oh, I totally echo that. And then I'll take, I guess a little bit more of a micro or unit level view and just really encourage people to be available. You know, if you hear that something strange happened or you were at work and you witnessed something, be willing just to check in with those people involved and ask them how they're doing. You know, even on a busy day, we do live in a very nice technological era. So, you know, a quick text to say, hey, you know, you seem a little down today, you know, let me know if you wanna talk, I'm here. Just making yourself available and reaching out, I think it kind of sets that base level where people feel comfortable coming out and talking about things that are bothering them. And certainly if anyone in our audience is, you know, kind of suffering with some of these things, we encourage you to reach out to other people in your organization and seek the help that potentially can help you stay in your current role, help you feel confident and get through what we've had identified as, you know, a potentially protracted process of recovery. You know, we hate to lose talented and well-educated and committed professionals. And I think we're gonna lose quite a few just because of the general moral distress that so many people are feeling in general, taking care of critically ill patients in such difficult circumstance. But for individuals, please use the resources that you have. And as you get through, if you don't have the resources, you know, again, ask questions and promote the development of resources that others may need. So at this point, I'd like to thank our speakers and thank our audience. And again, wish SCCM a happy 50th anniversary and hope our listeners enjoy the rest of the virtual Congress. Thank you very much to both Jenny and Brian for some excellent discussion. Thank you.

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