Transition To Residency · Year 4 · from Transition To Residency
Case 2: Second Victim and Error Disclosure
Clinical Image
Source: Wikipedia - Patient safety - CC BY-SA 4.0
Case Presentation
A 28-year-old male internal medicine intern fails to follow up on a CT scan showing a pulmonary embolism in a 55-year-old female admitted for shortness of breath. The result was posted in the chart at 11 PM but the intern, exhausted after a 28-hour shift, signed out without reviewing pending studies. The covering physician assumed the day team had addressed all results. The patient was discharged the next morning by the incoming team who also missed the result. Three days later, the patient presents to the ED with massive PE and dies despite resuscitation efforts. The intern is devastated, experiencing intense guilt, shame, and questioning whether he should continue in medicine. He is unable to sleep and replays the events constantly. His program director recognizes signs of second victim syndrome and connects him with peer support and EAP counseling. He participates in disclosure to the family with the attending, expressing sincere apology for the failure. The incident leads to implementation of a mandatory critical results notification system. Through processing with support, the intern gradually integrates the experience, recognizing that while his error contributed, system failures in result notification played a major role. He becomes an advocate for patient safety and eventually presents the case at a national conference.
Key Learning Points
- When errors occur, systematic response includes patient stabilization, reporting, documentation, disclosure, and learning activities
- Medical error disclosure requires honesty about what happened, expression of sincere apology, explanation of contributing factors, and commitment to prevention
- Second victim syndrome affects healthcare workers involved in adverse events and requires recognition, peer support, professional resources, and organizational support