The Second Victim Phenomenon: Perspective of Canadian Radiation Therapists.

INTRODUCTION: Clinical incidents are an unfortunate reality in the health care system. Patients and their families are the first victims of these incidents. The health care providers involved in the error are considered the second victims. This research aimed to evaluate the level of awareness of the second victim phenomenon (SVP) in Canadian radiation therapists, determine the post-incident emotional and physical reactions experienced, and determine the existing and/or recommended systems for support. METHODS: Mixed method design comprised two phases. In phase I, Canadian radiation therapists were invited to view an informational presentation about the SVP and complete an online survey. In phase II, participants partook in an online discussion forum. RESULTS: Survey results indicate that 31% of respondents were previously aware of the SVP and 86% of respondents report having been involved in a clinical incident. In addition, the results confirm that Canadian radiation therapists who have been involved in health care-related incidents do experience emotional and physical reactions. Most respondents indicated they lacked appropriate organizational support to help them recover from the clinical incident. Support from a colleague is the preferred method of support immediately after the incident. Finally, survey respondents indicated a clear desire for implementation of defined processes for postclinical incident supports. DISCUSSION: The reported level of awareness of the SVP surprised the authors as it was anticipated to be lower; however, there is an obvious need for greater knowledge of the subject. Reported frequency of involvement in a clinical incident as well as the post-clinical reactions experienced are comparable for other health care providers as indicated in the literature. Survey results revealed that emotional and physical reactions were experienced to a greater degree in those unfamiliar with the SVP, indicating potential value to adding an educational component to radiation therapist's training programs as well as on the job training for staff in the workforce. Most respondents requested specific methods of support for recovery after a clinical incident. In addition, an unexpected number of radiation therapists indicated the need for a "no-blame" work environment, which was an unanticipated finding. CONCLUSION: This study highlights the lack of awareness of the SVP in Canadian radiation therapists. It identifies the gap between the needs of the second victims and the perceived lack of supports offered by their facilities. This issue is important for organizations wanting to positively manage clinical incidents and create a culture of safety for the patients and employees.

A Case of Waldenstrom's Macroglobulinemia Morphologically Resembling Plasma Cell Myeloma.

Although both are characterized by the presence of an IgM monoclonal gammopathy, IgM multiple myeloma and Waldenstrom's macroglobulinemia are two distinct hematologic entities. Differentiation of each however, may be challenging, but obviously critical to ensuring appropriate therapeutic decision-making and patient prognostication. Herein we report a case of a patient with Waldenstrom's macroglobulinemia presenting with bone marrow morphology mimicking plasma cell myeloma, highlighting the importance of clinical correlation and ancillary studies to reach an appropriate diagnosis.

Guidelines on the use of intravenous immune globulin for hematologic conditions.

Canada's per capita use of intravenous immune globulin (IVIG) grew by approximately 115% between 1998 and 2006, making Canada one of the world's highest per capita users of IVIG. It is believed that most of this growth is attributable to off-label usage. To help ensure IVIG use is in keeping with an evidence-based approach to the practice of medicine, the National Advisory Committee on Blood and Blood Products of Canada (NAC) and Canadian Blood Services convened a panel of national experts to develop an evidence-based practice guideline on the use of IVIG for hematologic conditions. The mandate of the expert panel was to review evidence regarding use of IVIG for 18 hematologic conditions and formulate recommendations on IVIG use for each. A panel of 13 clinical experts and 1 expert in practice guideline development met to review the evidence and reach consensus on the recommendations for the use of IVIG. The primary sources used by the panel were 3 recent evidence-based reviews. Recommendations were based on interpretation of the available evidence and where evidence was lacking, consensus of expert clinical opinion. A draft of the practice guideline was circulated to hematologists in Canada for feedback. The results of this process were reviewed by the expert panel, and modifications to the draft guideline were made where appropriate. This practice guideline will provide the NAC with a basis for making recommendations to provincial and territorial health ministries regarding IVIG use management. Specific recommendations for routine use of IVIG were made for 7 conditions including acquired red cell aplasia; acquired hypogammaglobulinemia (secondary to malignancy); fetal-neonatal alloimmune thrombocytopenia; hemolytic disease of the newborn; HIV-associated thrombocytopenia; idiopathic thrombocytopenic purpura; and posttransfusion purpura. Intravenous immune globulin was not recommended for use, except under certain life-threatening circumstances, for 8 conditions including acquired hemophilia; acquired von Willebrand disease; autoimmune hemolytic anemia; autoimmune neutropenia; hemolytic transfusion reaction; hemolytic transfusion reaction associated with sickle cell disease; hemolytic uremic syndrome/thrombotic thrombocytopenic purpura; and viral-associated hemophagocytic syndrome. Intravenous immune globulin was not recommended for 2 conditions (aplastic anemia and hematopoietic stem cell transplantation) and was contraindicated for 1 condition (heparin-induced thrombocytopenia). For most hematologic conditions reviewed by the expert panel, routine use of IVIG was not recommended. Development and dissemination of evidence-based guidelines may help to facilitate appropriate use of IVIG.

Co-existence of heparin-induced thrombocytopenia and thrombotic thrombocytopenic purpura in a postoperative cardiac surgery patient.

Up to 50% of patients undergoing coronary artery bypass surgery will develop antibodies against the heparin-platelet factor 4 complex, and a small percentage of those will go on to develop heparin-induced thrombocytopenia. Thrombotic thrombocytopenic purpura has also been reported post-coronary artery bypass surgery. In this case report, we describe a patient who developed both heparin-induced thrombocytopenia and thrombotic thrombocytopenic purpura post-coronary artery bypass surgery. This patient had clinical features consistent with both entities, and the clinical picture could not be explained by either heparin-induced thrombocytopenia or thrombotic thrombocytopenic purpura alone. It is hypothesized that these two entities may be related in this patient population, and this case report emphasizes the challenges in the diagnosis of thrombocytopenia in this patient population.