The impact of adverse events can be devastating not only for patients and families but also for the caregivers involved. The first victim refers to the patient, and the second victim (SV) is a term used to describe the emotional impact experienced by caregivers.
Second victims are healthcare providers who are involved in an unanticipated adverse patient event, in a medical error and/or a patient related injury and become victimized in the sense that the provider is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base. (Scott et.al., 2009, p. 326).
How prevalent is this? In a survey conducted in the United States and Canada with more than 3000 physician respondents, 92% were involved in safety events varying from near misses to serious safety events. The majority of respondents reported experiencing stress related to these events. Individual responses depended on the gravity of the error(s), perception of responsibility, and the impact on the patient (AHRQ, 2019). This article/chapter will discuss symptoms experienced by the SV, stages of response, supportive strategies, and a case example involving a nurse and the use of an unfamiliar catheter resulting in patient harm.
Symptoms of the Second Victim
SVs may experience a range of symptoms in the categories of physical, emotional, psychological, and professional. These may stem from their own critical internal negative dialogue and judgment from others. See Table 1 below for a few examples of these:
Table adapted from Tamburri, L. (2017)
Qualitative interviews of potential second victims conducted at the University of Missouri Health Care (MUHC) system showed a consistent theme among all participants- all reported their experience as being life-altering, and leaving a lasting experience on them (Scott, 2011). “One clinician described his second victim experience as an “emotional tsunami,” unlike anything he had ever experienced before in his professional career” (Scott, 2011, para.8). In addition, the emotional effects can be long-lasting, depending on the severity of the event, with consequences similar to those seen with posttraumatic stress disorder (Ozeke et al, 2019).
The SV is described as going through the following stages of response by Scott et.al. (2009):
This begins with the clinician trying to process what happened, amidst the chaos of what could still involve managing an unstable patient. Additional providers may be required to assist the situation. The second stage is characterized by the victim reliving the event and considering “what if” scenarios, along with feelings of insufficiency and doubt. The third stage is characterized by seeking support from trusted individuals. Stage 4 involves working through the institutional reaction to the event. This may involve a root cause analysis and investigation with quality/safety and risk management personnel. SVs may experience concerns around job security, potential litigation, and licensure. The fifth stage includes seeking emotional support from loved ones or colleagues.
The last stage, moving on, occurs in one of three ways: dropping out, surviving, or thriving. Dropping out could range from changing to a different practice location or specialty to leaving the profession altogether. Surviving describes maintaining performance but continuing to be haunted by the event. Thriving describes the ability to learn and grow from the event, using it to change practice or become involved in broad-scale changes. These individuals are able to create positive change as a result. (Scott et.al, 2009).
Supporting second victims can be accomplished in a variety of ways:
- Support personnel: clergy, social workers, clinical psychologists, counselors
- Hospitals employee assistance programs
- Mental health counseling
- Team debriefing after the event
- Clinical Leaders- by providing emotional support and showing empathy
- If able, allowing for some time off and helping to arrange coverage
- Addressing disrespectful behavior such as gossip or incivility by others
- Colleagues including mentors and supervisors- by providing emotional and informational support.
- These are staff that understands the nuances of the clinical situation and can provide insight.
- Formal support programs are provided by healthcare organizations- for example, Johns Hopkins Hospital has a peer support program in place using a volunteer multidisciplinary healthcare team called Resilience in Stressful Events (RISE). These volunteers help to provide a safe space for discussing the emotional impact of the event (Ozeke et al, 2019).
In addition to providing support to the SV in the above-mentioned ways, the investigation into the event to determine of root causes of errors is common. This will identify any individual or system failures and provide an opportunity to improve processes and prevent future events from occurring.
The following is an example of a nurse who became a second victim as a result of an event involving an unfamiliar catheter resulting in patient injury. This example was taken from the Agency for Healthcare Research and Quality Patient Safety Network Web M&M Case Series (Swayze & James, 2013, paras 1-4).
A 28-year-old woman, 20 months post–bilateral lung transplant, presented to the emergency department with sudden onset of severe shortness of breath and was admitted to the hospital. Diagnostic studies revealed that she was producing donor-specific antibodies. A large bore central line, similar to a hemodialysis catheter, was placed in her right chest, and daily bedside plasmapheresis therapy was initiated as treatment for humeral rejection.
A registered nurse (RN) received orders to draw the patient’s morning labs. Although she had worked with many other types of catheters, the RN asked the charge nurse for instructions because she had no previous experience with this type of catheter. The charge nurse provided the RN with the following basic verbal instructions: waste 3 cc, draw labs, flush with saline, HEP-LOCK. The RN felt confident that the verbal instructions were sufficient.
The patient was awake and in no apparent distress when the RN entered her room. The two chatted as the RN drew the patient’s labs. After all the tubes had been filled the patient sat upright and said, “Something isn’t right.” As the RN reached around the bedside table to grab the saline flush, the patient began to convulse. The RN called for help as the patient lost consciousness and fell, bleeding from her catheter, to the floor. The patient spent the next 3 days in the intensive care unit (ICU). She was conscious yet unable to respond for the first 24 hours. Testing revealed a cerebral air embolism, and the medical opinion was that damage was likely to be temporary.
The nurse manager conducted an immediate and thorough incident review, which revealed that the RN had failed to clamp the catheter prior to removing the syringe, thus allowing air to enter the catheter and obstruct the patient’s circulatory system. The devastated RN requested a temporary leave of absence, but never returned to work. The hospital enacted a policy allowing only trained RNs to access the catheters and requiring all RNs to receive mandatory education.
In this case, improved training, credentialing, and supervision given her inexperience with this particular catheter might have prevented this safety event from occurring. In addition, providing adequate emotional/mental health support following this event would have been warranted.
Unfortunately in healthcare, bad things happen to well-meaning individuals working within an imperfect system. When unexpected safety events occur, having an infrastructure in place, involving support personnel and programs, can help individuals work through the various stages of response and effectively move forward.
Agency for Healthcare Research and Quality (AHRQ) (2019). Second Victims: Support for Clinicians Involved in Errors and Adverse Events. Retrieved from https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
Ozeke, O., Ozeke, V., Coskun, O., & Budakoglu, I. I. (2019). Second victims in health care: Current perspectives. Advances in Medical Education and Practice, Volume 10, 593-603. doi:10.2147/amp.s185912
Ryan, L. (n.d.) Supporting Second Victims. Retrieved from https://www.rn.com/headlines-in-health/supporting-second-victims/
Scott, S. (2011). The Second Victim Phenomenon: A Harsh Reality of Healthcare Professions. (n.d.). Retrieved from https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall L. The natural history of recovery for the health care provider is “second victim” after adverse patient events. Qual Saf Health Care. 2009;18(5):325-30.
Tamburri, L. M. (2017). Creating Healthy Work Environments for Second Victims of Adverse Events. AACN Advanced Critical Care, 28(4), 366-374. doi:10.4037/aacnacc2017996
Copyright by Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS