“Virtually every practitioner knows the sickening realisation of making a bad mistake.”
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In 2000, Albert Wu illustrated the damaging psychological consequences following medical errors devising the term second victim, describing the emotional turmoil experienced by a health care professional. The patient and family are the first victims, and the health care professional is the second.Second victim syndrome is an underappreciated phenomenon with considerable consequence to those affected and the organizations in which they work. Affected health care professionals can experience shame, anxiety, and depression following an adverse event, with the prevalence of second victims estimated to be in the range of 10%-43%.
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One study of surgeons reported a prevalence of 91%.3
Although individuals in the medical profession are sometimes seen as infallible, second victim syndrome is a stark reminder that mistakes are an intrinsic part of medical practice.- Jain G.
- Sharma D.
- Agarwal P
- et al.
“Second Victim” Syndrome among the surgeons from South Asia.
Indian J Surg. 2019; https://doi.org/10.1007/s12262-021-02793-3
Medical errors, such as medication dosing errors, are the third-leading cause of death in the United States leading to more than 250,000 deaths per year.
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Statistics highlighting the detrimental effects of medical errors are shocking, yet it is important to consider that even unintended complications of a procedure could result in second victim syndrome. In addition to the effects on the patient, it is imperative to consider the psychological impact on the health care provider. Physicians often expect an idealistic level of perfection and, therefore, struggle to cope with the effects of error.Chung AS. Second victim syndrome. In: EMRA Wellness Guide. Available at: http://www.emra.org/books/emra-wellness-guide/ch-8.-second-victim-syndrome. Accessed November 15, 2021.
Second victims experience intrusive emotions such as anxiety, depression, diminished confidence, and loss of job satisfaction.
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These emotions vary depending on the context. A surgeon who makes an operative mistake may take singular responsibility and, therefore, experience the intense burden of an error “under their hands.”6
In extreme scenarios, the despair experienced has resulted in suicide.4
These upsetting emotions may last weeks, and even years, and can manifest with a state that mimics posttraumatic stress disorder. The downstream effects of a medical error can impact the care of future patients treated by the health care professional.Chung AS. Second victim syndrome. In: EMRA Wellness Guide. Available at: http://www.emra.org/books/emra-wellness-guide/ch-8.-second-victim-syndrome. Accessed November 15, 2021.
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When under pressure, providers may feel engrossed by their emotions, negatively impacting decision-making and performance. As a result, studies discovered that health care professionals who are second victims are at higher risk of being implicated in a subsequent error. Effects beyond the second victim have been termed the third victim (ie, hospital reputation) and the fourth victim (ie, patients subsequently harmed in the future).2
Second victim syndrome is not unique to the medical profession; the military and emergency services have also encountered this issue. Therefore, health care organizations should consider lessons learnt from these services with excellent institutionalized care for their workers.
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Scott et al
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identified a predictable pattern of recovery for second victims (Table). The first 3 stages can happen concurrently, or in quick succession. They summarize a chain of thoughts beginning from initial chastising and turmoil (stage 1) to feelings of inadequacy and questioning how the situation may have been prevented (stage 2, “what if” scenarios). During the third stage, where the provider questions their acceptance within the workplace, support becomes vital. Encouragement from a peer or mentor can be the foundation of their recovery. Subsequently, it is essential that health care organizations create supportive environments that allow sources of support to come to fruition.Table 1The 6 Stages of Recovery from Second Victim Syndrome
| Stages of Recovery | Internal monologue which may be experienced at the time |
|---|---|
| Stage 1: Chaos and accident response | “I'm in shock, how did this happen? What can we do to protect the patient from further harm?” |
| Stage 2: Intrusive reflection | “How did I let this happen? Could I have acted differently?” |
| Stage 3: Restoring personal integrity | “How will my colleague judge me? Will I ever regain my reputation?” |
| Stage 4: Enduring the inquisition | “What will happen to my job? Will I get dismissed? Will I get sued?” |
| Stage 5: Obtaining emotional first aid | “Who can I turn to for support?” |
| Stage 6: Moving on | |
| Dropping Out Surviving Thriving | “I feel inadequate. Is this the right job for me?” “I made it through but the mistake replays in my thoughts. I can't let it go.” “It was an awful experience, but I have learnt from this. Overall, it will make me a better person for the future” |
The third stage of the recovery process correlates to the first opportunity that a health care organization can act, not necessarily through direct intervention, but through adapting their culture. If organizations shift from a blame culture to a safety culture, in which the health care professional does not feel the onus of responsibility but rather the sympathy from their workplace, it may be possible to obtain improved psychological outcomes and avoid the creation of a devastated second victim. A supportive environment may additionally enable a conducive setting for learning from the error and identifying future measures. This can be achieved by fostering relationships across all health care disciplines from management to the health care professional. Health care organizations should schedule regular, open, and honest morbidity and mortality safety conferences to provide a secure setting for disclosing and discussing errors.
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In the long term, this may foster a safety culture, rather than one of blame and fear.11
Health care organizations may intervene at other segments of the recovery trajectory to enhance outcomes. Once the internal unrest of the first 3 stages is encountered, further issues to address include litigation, job security, and available longitudinal support (stages 4 and 5). A substantial component of the tumult created by second victim syndrome is due to the provider focusing on the ramifications of the error. Health care organizations, and even independent regulators, can ameliorate concerns through increased awareness and transparency of hospital policy when an error occurs. This may be achieved through second victim response teams, consisting of a multidisciplinary panel of peers, trained psychologists, hospital managers, and lawyers, who can empathetically guide the health care professional when an incident occurs. When deployed in the immediate aftermath of an error, response teams demonstrated enhanced recovery of the second victim at the University of Missouri Health Care.
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This institution used a tier system of care: Tier 1 refers to a shift in workplace culture from blame to support. Tier 2 is provided by trained peer support and patient safety officers who deliver 1-on-1 crisis intervention following an event. Tier 3 involves a referral network to clinical psychologists and social workers to provide the health care professional with further support.When delivering emotional first aid, the rights of the second victim should be considered. This is proposed by the acronym TRUST:
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Treatment that is just, Respect, Understanding and compassion, Supportive care, and Transparency and opportunity to communicate. Each of these rights stems from an underlying principle that the health care professional has good intentions and relies on their employer for sympathy, support, and shared accountability. If organizations can systemically enact these 5 principles and create hospital-wide frameworks that put these values first, then a greater proportion of second victims may thrive (stage 6).Although much of the prevention and management of second victim syndrome focuses on reframing safety culture and establishing response teams, small measures can increase awareness in the short term. Health care organizations should share existing sources of support to health care professionals such as the Institute for Safe Medication Practices, which has an error reporting program with the goal of preventing future medication errors (www.ismp.org/report-medication-error). Hospitals can produce checklists that guide providers through disclosing errors after an event.
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Although 90% of trainees desire disclosure training, one-third of providers receive it.4
Addressing this gap may mitigate the psychological harm of second victim syndrome because the health care professional can feel greater confidence when dealing with mistakes, thereby fostering a transparent adverse event policy and patient-safety culture. Nearly every health care professional will encounter a mistake or complication over their career; therefore, having adequate preparation would be beneficial.Chung AS. Second victim syndrome. In: EMRA Wellness Guide. Available at: http://www.emra.org/books/emra-wellness-guide/ch-8.-second-victim-syndrome. Accessed November 15, 2021.
Second victim syndrome highlights a broader issue: How health care organizations must value and protect their workers’ mental health. This is pertinent in the wake of the coronavirus disease 2019 (COVID-19) pandemic in which health care professionals have been overwhelmed with challenging decisions. With an increased shortage of health care professionals, organizations cannot afford to lose employees to second victim syndrome. To retain workers and protect patient safety, organizations must share responsibility for the mental well-being of those working within clinical settings and ensure adequate support is available when medical errors inevitably occur.
References
- Medical error: the second victim.BMJ. 2000; 320: 726-727
- Second victims in health care: current perspectives.Adv Med Educ Pract. 2019; 10: 593-603https://doi.org/10.2147/AMEP.S185912
- “Second Victim” Syndrome among the surgeons from South Asia.Indian J Surg. 2019; https://doi.org/10.1007/s12262-021-02793-3
Chung AS. Second victim syndrome. In: EMRA Wellness Guide. Available at: http://www.emra.org/books/emra-wellness-guide/ch-8.-second-victim-syndrome. Accessed November 15, 2021.
- The emotional impact of medical errors on practicing physicians in the United States and Canada.Jt Comm J Qual Patient Saf. 2007; 33: 467-476https://doi.org/10.1016/s1553-7250(07)33050-x
- When things go wrong: the surgeon as second victim.Ann Surg. 2019; 269: 808-809https://doi.org/10.1097/SLA.0000000000003138
- Care of the clinician after an adverse event.Int J Obstet Anesth. 2015; 24: 54-63https://doi.org/10.1016/j.ijoa.2014.10.001
- The second victim requires more than Medice Cura Te Ipsum.Can Urol Assoc J. 2021; 15: S40-S42https://doi.org/10.5489/cuaj.7229
- The natural history of recovery for the healthcare provider “second victim” after adverse patient events.Qual Saf Health Care. 2009; 18: 325-330https://doi.org/10.1136/qshc.2009.032870
- Humanizing the morbidity and mortality conference.Acad Med J Assoc Am Med Coll. 2021; 96: 668-670https://doi.org/10.1097/ACM.0000000000003901
- Cultures for improving patient safety through learning: the role of teamwork*.Qual Health Care QHC. 2001; 10: ii26-ii31https://doi.org/10.1136/qhc.0100026
- Caring for our own: deploying a systemwide second victim rapid response team.Jt Comm J Qual Patient Saf. 2010; 36: 233-240https://doi.org/10.1016/s1553-7250(10)36038-7
- Medical errors; causes, consequences, emotional response and resulting behavioral change.Pak J Med Sci. 2016; 32: 523-528https://doi.org/10.12669/pjms.323.9701
Article Info
Publication History
Published online: February 04, 2022
Footnotes
Funding: None.
Conflicts of Interest: EOK reports consulting fees from Spineart and Seaspine. AHD reports consulting fees from Stryker, Orthofix, Spineart, and EOS, research support from Southern Spine, and Fellowship support from Orthofix. MdK, DA, CLM report none.
Authorship: All authors had access to the data and a role in writing this manuscript.
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© 2022 Elsevier Inc. All rights reserved.
