The Toll of Adverse Patient Outcomes on Healthcare Providers: Supporting Second Victims

Laura M. Cascella, MA, CPHRM

Any approach for managing adverse outcomes in healthcare, including medical errors, should prioritize the patients who these situations affect. Patients are considered the “first victims” of adverse outcomes, and healthcare organizations and providers have a duty to provide them with truthful information, follow-up care, and emotional support.

Adverse outcomes also can have a traumatic effect on others involved, including healthcare providers and staff. The term “second victims” was coined to describe healthcare providers involved in adverse patient outcomes who feel traumatized by the events. These providers may experience feelings of blame, anger, shame, failure, depression, inadequacy, and distress.¹

With research suggesting that medical errors are a leading cause of death in the United States,² the issue of second victims is a considerable concern for healthcare organizations. A survey of more than 3,000 physicians in the United States and Canada showed that about 9 out of 10 respondents had been involved in incidents ranging from near misses to serious errors, and most of these individuals reported feeling some degree of stress related to the events. Further, estimates suggest that as many as half of all clinicians will be involved in serious adverse events during their careers.³

How healthcare providers react to adverse outcomes can depend on various factors, including the seriousness of the circumstance, the person’s role and perception of responsibility, the patient’s outcome, and organizational response.⁴ In some cases, providers might experience minor stress or anxiety that dissipates in the days and weeks following an incident. Other providers might suffer from strong emotional reactions and symptoms akin to those of posttraumatic stress disorder — i.e., second victim phenomenon. The emotional toll of an unanticipated outcome can be so severe that it may even lead to suicidal ideation or actions.⁵

Regardless of how the second victim phenomenon manifests, it can have a serious impact on healthcare providers’ personal and professional lives — and, as a consequence, can be detrimental to patient safety and organizational culture. For these reasons, healthcare organizations should consider the systems they have in place to support practitioners and staff involved in adverse outcomes.

Although more research is needed on how best to address second victim issues in healthcare, organizations can proactively establish supportive policies and programs. Suggested strategies include the following:

• Create policies that help establish a culture of safety that encourages transparency, respect, and honesty. Punitive policies and measures in response to adverse outcomes can create barriers to disclosure of incidents and emotional coping.
• Survey healthcare providers/staff about organizational culture, and conduct an organizational assessment to determine how best to support individuals involved in adverse outcomes.
• Develop written policies and procedures for second victim support and resources. Educate organizational leaders, providers, and staff about these resources and how to access them.
• Implement a comprehensive program to support providers before, during, and after disclosure of adverse outcomes. As part of the program, understand and recognize the six stages of recovery for second victims: (1) chaos and accident response, (2) intrusive reflections, (3) restoring personal integrity, (4) enduring the inquisition, (5) obtaining emotional first aid, and (6) moving on.⁶
• As part of your organization’s second victim support program, consider options such as:
  • Unit- or department-based support systems.
  • Tiered levels of response to address a range of emotional outcomes and support needs.
  • Rapid response teams.
  • Peer support/mentoring.
  • Employee assistance programs.
  • Easily accessible support hotlines or contacts
  • Professional review/feedback.
  • Expert consultants (e.g., risk managers, patient safety experts, mental health professionals).
  • Support materials (e.g., tips for managing stress, self-care guidance, crisis management).
  • Professional counseling.⁷
• Establish confidentiality standards for information shared as part of second victim support programs, and monitor to ensure adherence to these standards.
• Educate and train providers/staff on the organization’s disclosure policies so they are prepared to handle a disclosure scenario. Feeling ill-prepared for disclosing an adverse outcome might create undue anxiety and stress. Consider role-playing or simulation exercises to provide hands-on education.

Supporting second victims is a vital component of responding to adverse outcomes. In an environment already fraught with pressure, the trauma from adverse outcomes can combine with other stressors — such as workforce shortages and burnout — to undermine providers’ health and well-being. Taking proactive steps to develop policies, procedures, and educational initiatives that support second victims will help reinforce a culture of safety.

For more information about supporting second victims of adverse outcomes, see the Agency for Healthcare Research and Quality's Second Victims: Support for Clinicians Involved in Errors and Adverse Events and the Institute for Healthcare Improvement's Respectful Management of Serious Clinical Adverse Events. Additional MedPro resources include Risk Q&A: Managing Stress After an Adverse Patient Outcome and Litigation Support: Maintaining Your Balance.

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¹ Agency for Healthcare Research and Quality. (2019, September). Second victims: Support for clinicians involved in errors and adverse events. Patient Safety Network. Retrieved from https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

² Makary, M. A., & Daniel, M. (2016, May). Medical error—the third leading cause of death in the US. The BMJ, 353, i2139. Retrieved from http://www.bmj.com/content/353/bmj.i2139

³ Agency for Healthcare Research and Quality, Second victims: Support for clinicians involved in errors and adverse events.

⁴ Ibid.

⁵ Grissinger, M. (2014). Too many abandon the "second victims" of medical errors.
P & T : A Peer-Reviewed Journal for Formulary Management, 39(9), 591–592.

⁶ Scott, S. D., Hirschinger, L. E., Cox, K. R., McCoig, M., Brandt, J., & Hall, L. W. (2009). The natural history of recovery for the healthcare provider “second victim” after adverse patient events. BMJ Quality & Safety, 18, 325-330. Retrieved from https://qualitysafety.bmj.com/content/18/5/325.info

⁷ Agency for Healthcare Research and Quality, Second victims: Support for clinicians involved in errors and adverse events; Institute for Healthcare Improvement. (2011). Respectful management of serious clinical adverse events (Second Edition). Retrieved from www.ihi.org/resources/Pages/IHIWhitePapers/RespectfulManagementSeriousClinicalAEsWhitePaper.aspx

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