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Tony's Story


It was like any other Friday evening shift for Tony, an RN with more than 17 years of critical care nursing experience.

He was assisting in a routine procedure requiring moderate sedation. Towards the end of the procedure, the patient suffered an unexpected cardiopulmonary arrest. Despite 60 minutes of resuscitation, the patient was ultimately pronounced dead. The family declined an autopsy.

On Monday morning, the patient safety officer began investigating the unexpected death and uncovered no preventable system or technical proficiency issues. Through this investigation, one of the most surprising and disturbing findings was the emotional struggle the nurse had endured through the weekend.

Tearfully, Tony painfully described how he relived every moment of the case countless times. Our investigator remembers how he second guessed his care, scrupulously reviewing in his mind the frequency and results of vital signs or other subtle clinical changes.

He described inability to concentrate on anything other than this patient experience, even while away from the hospital for almost 3 days. He had been experiencing horrible headaches, severe nausea and insomnia. Despite his best efforts, he couldn't shake the recurring thoughts of his final conversation with the patient. He was experiencing an internal crisis of huge proportions with one repetitive thought - he wasn't good enough to be a nurse and should leave the profession!

Tony was suffering in silence as a second victim! His story was a critical milestone in the Office of Clinical Effectiveness (OCE) journey to help understand the second victim phenomenon. His powerful story helped fuel our desire to learn more about this relatively unknown phenomenon affecting today's health care providers. Tony's story encouraged each of the forYOU Charter Team members to keep pursuing a more thorough understanding of this silent epidemic.

University of Missouri Health System's (MUHS) forYOU Team is dedicated to 'Tony' and his many colleagues who choose to face stressful clinical events each and every day to help improve the lives of those under our care.

*Tony's story is based on an actual case that occurred within MUHS. Tony's name has been changed to protect his privacy




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