S​‌‍‍‍‌‍‍‌‍‌‌‍‍‍‌‍‌‌‌‍​cenario: Resident left facility unassisted by staff or family, he was located laying on the main road between two parked cars. Onlookers had flagged down a passing ambulance and the man was being assessed for injuries, at this point a registered nurse on duty attended the scene and without assessing the resident advised the other staff to bring resident back into facility after the medics had assessed him if they didn’t transfer him to the emergency department. Medics assessed and declined the need for transfer and resident was brought back into facility and returned to his room where care staff assessed and treated wounds which included skin tears and grazes to the face, hands and legs. On commencing duty, the next AM, I was called to this resident’s room as he was vomiting, on entering the room I identified severe bruising to the left side of his face and he was pale and not responding appropriately. On completing neurological observations, I sought the advice of external parties and transfer to hospital was organized. Two days later the facility was notified that the man had passed away from a subdural haemorrhage. Investigation into this incident as there was an obvious head injury as wounds were present on his face included: • why wasn’t he taken to emergency department after being assessed by medics? • why was he not assessed by the registered nurse from the facility who attended the scene? • why did the registered nurse leave the scene and left care staff to evaluate and transfer back into facility? • How did he lea​‌‍‍‍‌‍‍‌‍‌‌‍‍‍‌‍‌‌‌‍​ve the facility with no staff aware of his whereabouts? Questions: Respond to the following questions in relation to the clinical situation identified above. Use sub-headings to identify each of the questions in your response. 1. Describe the short term and long-term impact of this clinical situation on the staff (second victims) involved in the event, in their professional roles and personal lives. 2. As an advanced practice nurse or nurse practitioner: describe the role and responsibilities of unit managers and senior clinicians who may be involved in responding to individual staff involved in an adverse event. What do these staff need in the aftermath of the event? 3. As an advanced practice nurse or nurse practitioner: Consider the impact of the event on team dynamics, communication, trust and perceived competence in the context of the organisational culture at that time. 4. What organisational reporting and/or investigation would be required in response to an event like this? What external reporting and/or investigation would be required in response to an event like this? 5. How should health care organisations support health professionals involved in adverse events? How should these organisations support health professionals during investigations of adverse events? Is there a need for clinical supervision following an adverse event? 6. How can second victims contribute to the prevention of adverse events?

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