In an earlier article on medical error I wrote for CPHQ Tutor, I shared a personal tragedy involving the death of a patient. What I did not mention was the anguish I felt over the loss of my patient, and what’s more, my contribution to his demise.
I felt guilty, apologetic, depressed, isolated, unsupported… it wasn’t a pleasant feeling at all.
In a British Medical Journal editorial1, Albert Wu, a professor at the Johns Hopkins Bloomberg School of Public Health, coined the term “second victim” to describe a healthcare provider who carries the brunt of a patient safety event, the latter often caused by a defective but highly unforgiving system. In my story above, I was a second victim. Given the high rate of adverse events in hospitals, the number of second victims is likely to be significant.
The symptomatology experienced by second victims shares similar emotional, psychological and behavioral characteristics with posttraumatic stress disorder: many victims feel considerable emotional distress brought about by a sense that they had failed the patient, question their clinical competence, and become ambivalent about their career choice.
Relatively little is known about the second victim phenomenon. This information could be extremely helpful in developing supportive programs, perhaps as part of a wider institutional response to preventable adverse events. In 2009, Scott and others2 reported interview findings with 31 second victims, which provided insight into how healthcare providers recover from an event.
Intensity of the Second Victim Phenomenon
Several factors were found to influence the intensity of the second victim experience among study participants:
- Relationship between the patient and the caregiver.
- Past clinical experiences.
- The patient being the same age as a family member of the caregiver or some other “connection.”
Due to the variable intensity of the response to an adverse event, second victims will require different levels of support.
Reliving the Event
Many victims relived the event—going through the same physical and/or psychological symptoms as they did when the event initially happened—when triggered by an external stimulus, e.g.:
- A different patient at the same location as the original event;
- A patient with a similar name;
- A patient with a similar diagnosis or clinical situation.
Predictable Natural History
The researchers concluded that the natural history of the second victim phenomenon is largely predictable, independent of sex, professional type and years in the profession. Recovery is characterized by six distinct stages:
Chaos and Accident Response
External and internal turmoil culminates in the realization that an adverse event has occurred. This is immediately followed by a period of rapid inquiry to find out what happened and of distraction and self-reflection. Victims often engage a peer for patient care.
This stage is marked by re-enactments, often accompanied by feelings of internal inadequacy and periods of self-isolation, as well as re-evaluations with “what if” questions.
Restoring Personal Integrity
In this stage, victims seek support from an individual whom they trust, e.g. a colleague, supervisor, personal friend or family member. Many participants in the study did not know to whom to turn as they couldn’t find anyone who could relate to their experience. Many also harbored doubts about the future of their professional career. Victims described a non-supportive, negative departmental “grapevine gossip” as a barrier to moving forward. Certainly, in my case, a “Don’t Ask, Don’t Tell” culture (deeply ingrained in many healthcare organizations) impeded my recovery.
Enduring the Inquisition
After the initial focus on stabilizing the patient (if he/she did not die) and the personal reflections, the second victim wonders about repercussions affecting job security, licensure, and future litigation.
Obtaining Emotional First Aid
During this phase of recovery, second victims seek support from loved ones, coworkers, supervisors or department chairs but the degree of support they receive is variable. They might not be clear where to go for support and what can be said due to professional and legal reasons.
Moving On—Dropping Out, Surviving or Thriving
Despite a desire to move on, many victims find it difficult to do so. This stage has three potential paths:
- Dropping Out—changing professional role, leaving the profession or moving to a different practice location.
- Surviving—performing at the expected performance levels (“doing OK”) but continue to be affected by the event.
- Thriving—making something good out of the adverse event.
Adverse patient events are largely the product of an imperfect system, not defective individuals—no healthcare professional ever wants these things to happen. When they occur, not only do patients and their families suffer but so do many of those who care for them. Effective and immediate surveillance and support strategies designed to assess and address the needs of second victims will help to alleviate their suffering, minimize premature exit from the profession, maintain satisfactory performance levels, and support a healthy patient safety culture.
Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000;320(7237):726–27. doi:10.1136/bmj.320.7237.726
Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events [Internet]. Quality and Safety in Health Care 2009;18(5):325–30. Available from: http://dx.doi.org/10.1136/qshc.2009.032870