September 15, 2022 • 11 mins
Expanding our Vocabulary – Second Victim
The person most proximal to the first victim, often the person who was the last line of defense to prevent the first victim, is the second victim, and suffers as well.
Dr Wu’s seminal paper https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117748/
Julie Thao’s story links :
Videos
- https://www.healthcareinnocenceproject.org/case-study-julie-thao/
- https://www.youtube.com/watch?v=Zkm2EaOPebY
- (please see this one) https://www.youtube.com/watch?v=30EAG6uW5DM
Articles:
Extraordinary Canadians: https://www.amazon.ca/Extraordinary-Canadians-Stories-Heart-Nation/dp/1982134526 (Robb Nash story)
Previous relevant Beyond the Minimum episodes:
https://beyondtheminimum.podbean.com/e/new-vocabulary-the-local-rationality-principle/
https://beyondtheminimum.podbean.com/e/expanding-our-vocabulary-hindsight-bias/
https://beyondtheminimum.podbean.com/e/expanding-our-vocabulary-the-second-story/
…
Connect with Tanya Hewitt on LinkedIn - https://www.linkedin.com/in/tanya-hewitt-55804529/
Buy her a coffee: https://www.buymeacoffee.com/tanyah
Credits:
Adam Johns – voiceover - https://www.linkedin.com/in/adamjohns730/
Beverley McKiver – composer and player of the music Tell Me About Love - https://www.linkedin.com/in/beverleymckiver/
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Adam Johns (00:03):
Welcome to Beyond the Minimum, where we'll be exploring the world of work. We'll be chatting about concepts, ideas and phrases, explore practices and delve into what good looks like. Work can be purposeful value lead, and more meaningful to all who interact with the workplace. This podcast is brought to you by Tanya Hewitt who lives in unceded Algonquin, Anishinaabeg territory, otherwise known as Ottawa, Ontario, Canada.
Tanya Hewitt (00:33):
Hello, everyone. I went to the post office recently, and there was a bit of a lineup, there were three of us in the line, I was the third, there was somebody before me. And there was somebody at the counter, who had a fairly complicated set of parcels to send out, it was taking quite a while I'll admit. The person in front of me, though, was in front of a lot of signs that say, we do not tolerate disrespect. We don't serve customers who are rude. We would like to treat each other with kindness, this kind of messaging. And I don't want to say that this customer was not respectful or rude or abusive. But he certainly demonstrated his impatience. There was no doubt that this customer was tapping his foot on the floor, leaning on the wall, sighing very loudly, and frustrated, because all he wanted to do was buy a stamp, where the customer in front of him was sending a number of parcels to different places, and weights and rates were being calculated. And it was rather complicated. The customer in front of me slammed his money on the counter and said "How much for stamp?" The person behind the counter quoted him the price and said," I'm sorry, I won't be able to
(02:04):
give you your change until I finished this transaction". He said, "Keep the change, give me the stamp." And he got hisstamp and marched out of there very quickly and abruptly. And I just realized that there might be reason to be rushed. I don't want to discredit that even, the customer at the counter had said "Yeah, well, you know, I can understand how frustrated he might have felt if he was in a rush." However, patience is something we need to start to really embrace because our world is changing. And we need to slow down and just embrace the opportunity to have a moment to ourselves even if we're in line and not express frustration in order to heighten tension to everyone else.
Adam Johns (02:59):
Today's episode is expanding our vocabulary.
Tanya Hewitt (03:06):
Today's expanded vocabulary term is the second victim. This term was established by Dr. Albert Wu in a year 2000 publication, it is open access, so it's going to be wonderful to share this in the show notes. Overall, it is the recognition of the last line of defense, the most proximal person to an event suffers as well. All right, to give justice to any one story, one needs to dive into the messy details and give context and environmental conditions, which I have done at conferences and talks with visual aids for the story that I'm just going to scratch the surface of here. So in short, I need to ask you to trust me as this episode would run for far too long if I truly set up that July 4th 2006 morning in a community hospital in Wisconsin. However, there is a video in the link that I will include in the show notes, that is about five and a half minutes long that can give you at least a snippet of what this story is about. So extraordinarily briefly, a very dedicated nurse had set up an epidural medication on an IV line which killed her pregnant patient. So the long story can be found in a number of sources that I will try to track down and put into the
(04:37):
show notes. But the main message I wanted to convey here is that she had to be taken to the psychiatry ward soon afterthis happened as she was at very high risk for suicide. Just to complete the story, she lost her license. She was charged criminally and can't practice in that field of medicine anymore, which is of course why I now know about this because this is part of a lot of the readings I have done in order to understand systems and a lot of the consequences when all we do is blame and punish. So the National Quality Forum of Safe Practice established the Care of the Caregiver program. And as far as I know, though my information could be quite dated now, Julie works, Julie Thao, who was the nurse in this incident, works to teach health care about system errors and second victims.
(05:42):
But I don't want this left as only a health care patient safety event. There is a broader idea here about anyone who isat the proximal end of usually a fatality. I just like to make it clear here, that we're not talking about people who actually deliberately plan harm. We are talking about people involved in accidents. Accidents, by definition, are not planned. Because of this, we need to realize the circumstances that people were in when we see a lot of blame and vengeance leashed on to those at the frontline. The idea is these were just people trapped in a larger system, not deliberately harm causing actors. So for example, parents who inadvertently leave a small child in a sweltering car, workers involved in workplace fatalities, some drivers in fatal car accidents. In a book, Extraordinary Canadians, an interaction with a truck driver, and an accident victim is reported as follows. So this is on pages 42 and 43. of Extraordinary Canadians. "I dialed the number and when the truck driver answered the phone, I told him, I was one of the kids in the car. I wanted to let you know that I'm okay. I'm alive. I survived." I said. There was silence on the other
(07:29):
end. Then he said, "I'm sorry about your friend." I didn't understand "Which friend?" The one who died", he said, Then Igot it. "No, no, that's me. I didn't die. I'm fine." The accident hadn't been his fault. But he felt tremendous guilt. Nevertheless, he barely knew how to share his emotions with me. All he could really say was, "You don't know what this means to me." The fact that the victim reached out to the person who was seen as guilty of this offense is a whole other conversation, but the truck driver harbored this guilt. He didn't even drive after that accident. And it seems as though he was very grateful for the victim's phone call.
(08:28):
A lot of this content is related to previous podcasts I have recorded, and I'll put the links in the show notes butspecifically, the local rationality principle released on April 7 2022, the fundamental attribution error released April 21 2022, hindsight bias, released August 4 2022, and the second story, released September 1 2022. Overall, this episode is to hopefully enlighten you that the person whom we want to blame who most others are out for blood in the wake of an accident, the person who was the very last line of defense in a much larger system wrought with human factors that led them to make the choices they did are suffering too, and they need care second victims. While they are usually the first to be blamed, they themselves are bathing in self blame and are desperately hurting. We need to start realizing that instead of automatically defaulting to guilt, we should realize that some people need much more care than blame.
(09:58):
I thank you for listening. I don't know if this is your first episode, or if you are a regular listener, having reallyappreciated some of this content. I just wanted to tell you that I really do appreciate you for listening. If you would like to express your gratitude for this podcast, I would encourage you to buy me a coffee, head on over to buy me a coffee.com/tanyah that's buy b-u-y me m-e a coffee c-o-f-f-e-e all one word.com/t-a-n-y-a-h tanyah. I will put this in the show notes. And I would really sincerely appreciate your support. In addition to that, you can rate and review this podcast and I really, really appreciate that you are here listening to what I am sending out to you guys. Thanks so much.
Adam Johns (11:10):
Thank you so much for listening to Beyond the Minimum with Tanya Hewitt. We hope this episode aligned with you. Maybe it was diametrically opposed to us at any rate, we trust it made you think the more we can think about our workplaces and start talking about them, the more we can collectively make a real difference. If you're living in Canada, please find out the Indigenous territory in which you reside. begin using it to introduce yourself. Please reach out to Tanya through her email Tanya@beyondsafetycompliance.ca. Connect and chat with her on LinkedIn. Follow her company Beyond Safety Compliance. And remember to ask yourself the question, How does your work look? Because we can always go Beyond the Minimum.
Welcome to Beyond the Minimum, where we'll be exploring the world of work. We'll be chatting about concepts, ideas and phrases, explore practices and delve into what good looks like. Work can be purposeful value lead, and more meaningful to all who interact with the workplace. This podcast is brought to you by Tanya Hewitt who lives in unceded Algonquin, Anishinaabeg territory, otherwise known as Ottawa, Ontario, Canada.
Tanya Hewitt (00:33):
Hello, everyone. I went to the post office recently, and there was a bit of a lineup, there were three of us in the line, I was the third, there was somebody before me. And there was somebody at the counter, who had a fairly complicated set of parcels to send out, it was taking quite a while I'll admit. The person in front of me, though, was in front of a lot of signs that say, we do not tolerate disrespect. We don't serve customers who are rude. We would like to treat each other with kindness, this kind of messaging. And I don't want to say that this customer was not respectful or rude or abusive. But he certainly demonstrated his impatience. There was no doubt that this customer was tapping his foot on the floor, leaning on the wall, sighing very loudly, and frustrated, because all he wanted to do was buy a stamp, where the customer in front of him was sending a number of parcels to different places, and weights and rates were being calculated. And it was rather complicated. The customer in front of me slammed his money on the counter and said "How much for stamp?" The person behind the counter quoted him the price and said," I'm sorry, I won't be able to
(02:04):
give you your change until I finished this transaction". He said, "Keep the change, give me the stamp." And he got hisstamp and marched out of there very quickly and abruptly. And I just realized that there might be reason to be rushed. I don't want to discredit that even, the customer at the counter had said "Yeah, well, you know, I can understand how frustrated he might have felt if he was in a rush." However, patience is something we need to start to really embrace because our world is changing. And we need to slow down and just embrace the opportunity to have a moment to ourselves even if we're in line and not express frustration in order to heighten tension to everyone else.
Adam Johns (02:59):
Today's episode is expanding our vocabulary.
Tanya Hewitt (03:06):
Today's expanded vocabulary term is the second victim. This term was established by Dr. Albert Wu in a year 2000 publication, it is open access, so it's going to be wonderful to share this in the show notes. Overall, it is the recognition of the last line of defense, the most proximal person to an event suffers as well. All right, to give justice to any one story, one needs to dive into the messy details and give context and environmental conditions, which I have done at conferences and talks with visual aids for the story that I'm just going to scratch the surface of here. So in short, I need to ask you to trust me as this episode would run for far too long if I truly set up that July 4th 2006 morning in a community hospital in Wisconsin. However, there is a video in the link that I will include in the show notes, that is about five and a half minutes long that can give you at least a snippet of what this story is about. So extraordinarily briefly, a very dedicated nurse had set up an epidural medication on an IV line which killed her pregnant patient. So the long story can be found in a number of sources that I will try to track down and put into the
(04:37):
show notes. But the main message I wanted to convey here is that she had to be taken to the psychiatry ward soon afterthis happened as she was at very high risk for suicide. Just to complete the story, she lost her license. She was charged criminally and can't practice in that field of medicine anymore, which is of course why I now know about this because this is part of a lot of the readings I have done in order to understand systems and a lot of the consequences when all we do is blame and punish. So the National Quality Forum of Safe Practice established the Care of the Caregiver program. And as far as I know, though my information could be quite dated now, Julie works, Julie Thao, who was the nurse in this incident, works to teach health care about system errors and second victims.
(05:42):
But I don't want this left as only a health care patient safety event. There is a broader idea here about anyone who isat the proximal end of usually a fatality. I just like to make it clear here, that we're not talking about people who actually deliberately plan harm. We are talking about people involved in accidents. Accidents, by definition, are not planned. Because of this, we need to realize the circumstances that people were in when we see a lot of blame and vengeance leashed on to those at the frontline. The idea is these were just people trapped in a larger system, not deliberately harm causing actors. So for example, parents who inadvertently leave a small child in a sweltering car, workers involved in workplace fatalities, some drivers in fatal car accidents. In a book, Extraordinary Canadians, an interaction with a truck driver, and an accident victim is reported as follows. So this is on pages 42 and 43. of Extraordinary Canadians. "I dialed the number and when the truck driver answered the phone, I told him, I was one of the kids in the car. I wanted to let you know that I'm okay. I'm alive. I survived." I said. There was silence on the other
(07:29):
end. Then he said, "I'm sorry about your friend." I didn't understand "Which friend?" The one who died", he said, Then Igot it. "No, no, that's me. I didn't die. I'm fine." The accident hadn't been his fault. But he felt tremendous guilt. Nevertheless, he barely knew how to share his emotions with me. All he could really say was, "You don't know what this means to me." The fact that the victim reached out to the person who was seen as guilty of this offense is a whole other conversation, but the truck driver harbored this guilt. He didn't even drive after that accident. And it seems as though he was very grateful for the victim's phone call.
(08:28):
A lot of this content is related to previous podcasts I have recorded, and I'll put the links in the show notes butspecifically, the local rationality principle released on April 7 2022, the fundamental attribution error released April 21 2022, hindsight bias, released August 4 2022, and the second story, released September 1 2022. Overall, this episode is to hopefully enlighten you that the person whom we want to blame who most others are out for blood in the wake of an accident, the person who was the very last line of defense in a much larger system wrought with human factors that led them to make the choices they did are suffering too, and they need care second victims. While they are usually the first to be blamed, they themselves are bathing in self blame and are desperately hurting. We need to start realizing that instead of automatically defaulting to guilt, we should realize that some people need much more care than blame.
(09:58):
I thank you for listening. I don't know if this is your first episode, or if you are a regular listener, having reallyappreciated some of this content. I just wanted to tell you that I really do appreciate you for listening. If you would like to express your gratitude for this podcast, I would encourage you to buy me a coffee, head on over to buy me a coffee.com/tanyah that's buy b-u-y me m-e a coffee c-o-f-f-e-e all one word.com/t-a-n-y-a-h tanyah. I will put this in the show notes. And I would really sincerely appreciate your support. In addition to that, you can rate and review this podcast and I really, really appreciate that you are here listening to what I am sending out to you guys. Thanks so much.
Adam Johns (11:10):
Thank you so much for listening to Beyond the Minimum with Tanya Hewitt. We hope this episode aligned with you. Maybe it was diametrically opposed to us at any rate, we trust it made you think the more we can think about our workplaces and start talking about them, the more we can collectively make a real difference. If you're living in Canada, please find out the Indigenous territory in which you reside. begin using it to introduce yourself. Please reach out to Tanya through her email Tanya@beyondsafetycompliance.ca. Connect and chat with her on LinkedIn. Follow her company Beyond Safety Compliance. And remember to ask yourself the question, How does your work look? Because we can always go Beyond the Minimum.
Popular Podcasts
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
The Joe Rogan Experience
The official podcast of comedian Joe Rogan.