Rev Cuid. 2025; 16(2): e5072

https://doi.org/10.15649/cuidarte.5072

EDITORIAL

Second victim phenomenon: impact on healthcare professionals, organizational responsibility and support strategies

 

Escola de Enfermagem da Universidade de São Paulo (EEUSP), PPGEn, GPQUALIS. São Paulo, Brazil. Email: maristelasanti@usp.br Correspondence Author Maristela Santini Martins
Bournemouth University. GPQUALIS. Bournemouth, Reino Unido. Email: hderezende@bournemouth.ac.uk Helena de Rezende
Juravinski Hospital, Hamilton Health Sciences. GPQUALIS. Hamilton, Ontario, Canadá. Email: sevillaqua@hhsc.ca Ellen Regina Sevilla Quadrado
Escola de Enfermagem da Universidade de São Paulo (EEUSP), PPGEn, GPQUALIS. São Paulo, Brazil. Email: andresa.paula@usp.br Andresa Gomes de Paula
Escola de Enfermagem da Universidade de São Paulo (EEUSP), PPGEn, GPQUALIS. São Paulo, Brazil. Email: hercules.enf@usp.br Hércules de Oliveira Carmo
Universidade do Estado de Mato Grosso (UNEMAT), Faculdade Indígena Intercultural. Barra do Bugres, Mato Grosso, Brazil. Email: vagnernascimento@unemat.br Vagner Ferreira do Nascimento

Highlights

 

How to cite this article: Martins, Maristela Santini; De Rezende, Helena; Quadrado, Ellen Regina Sevilla; De Paula, Andresa Gomes; Carmo, Hércules de Oliveira; Nascimento, Vagner Ferreira do. Second victim phenomenon: impact on healthcare professionals, organizational responsibility and support strategies. Revista Cuidarte. 2025;16(2):e5072. https://doi.org/10.15649/cuidarte.5072

Received: March 17th 2025
Accepted: March 27th 2025
Published: May 1st 2025

CreativeCommons 

E-ISSN: 2346-3414

Unsafe practices and incidents that result in negative patient outcomes can lead to potential victims. While patients are the primary and most apparent victims, healthcare workers also suffer from their mistakes, in that they experience trauma following the event1 and are deemed the second victims2. The term "second victim" (SV) was first described by Wu (2000), who proposed that physicians who make mistakes also need help. Later, Scott expanded the concept, defining SVs as professionals involved in a health error3. More recently, an international consensus proposed that an SV can be any healthcare worker—whether directly or indirectly involved in an adverse event (AE), unintentional error, or patient-related injury—who is also negatively impacted by the experience of becoming a victim4.

The occurrence of errors triggers stressors in the professionals involved, including psychological, cognitive, and/or physical reactions5. Prevalent manifestations include memory impairment, anxiety, self-directed anger, remorse, worry, fear of making a mistake again, sleep disturbances, and embarrassment in front of coworkers. Physical symptoms include fatigue, tachycardia, hypertension, tachypnea, and muscle tensionr6,7.

In a study involving 31 SVs, six stages were mapped. Initially, in the stage of responding to the incident and the onset of chaos, SVs experience emotional and cognitive overload as they grapple with disorganized thoughts, self-reflection, and attempts to understand what happened, all while managing a patient in crisis. Generally, they seek emergency support with the aim of stabilizing the first victim. In the stage of intrusive reflections, persistent thoughts of fear and guilt prevail, prompting a re-evaluation of the event and an ongoing search for explanations behind the error. In an attempt to restore their sense of personal integrity, SVs turn to trusted individuals, such as colleagues or family members, for support while also confronting self-criticism and concerns about their professional reputation3.

Subsequent stages involve more complex institutional and emotional challenges. In the enduring inquisition stage, anxieties about legal and disciplinary repercussions arise alongside physical and psychological symptoms, prompting SVs to the stage of obtaining emotional first aid. Psychological and legal support becomes critical, driving a need for safe spaces to express distress. In the moving on—dropping out, surviving or thriving stage, SVs may follow one of three paths: dropping out, surviving, or thriving, depending on the resilience and support received. This stage determines the event’s long-term impact, potentially leading to career withdrawal, staying but with emotional harm or strengths, and commitment to patient safety initiatives3. Not all SVs experience these stages sequentially; some may stall in progression.

The SV phenomenon affects healthcare teams worldwide. In the United Kingdom, 76% of professionals involved in near misses or adverse events reported experiencing emotional impacts8. In Central Europe, the phenomenon is also relevant. In Germany9, 59% of physicians reported feeling like SV following an AE, while in Austria, 43% reported this experience at least once after incidents of this nature10. In Belgium, general practitioners reported high levels of hypervigilance, guilt, stress, and shame. In Spain11, 70% of nurses and physicians reported having experienced the SV phenomenon either directly or indirectly, while in Italy, 41% presented psychological and physical symptoms, as well as an intention to leave their job following the event12.

Approximately 50% of healthcare professionals in Canada have reported being affected by SV experience at some point in their careers13,14. In the United States, an estimated 53% of pharmacists and 15% of pharmacy technicians identified themselves as SVs. Among pharmacists, 60% reported that it took between one week and one year to overcome the AE, while 20% reported needing more than a year or never recovering from the post-traumatic event15. In another study conducted in the United States with professionals who did not provide direct patient care, 26.7% of them reported having experienced the SV phenomenon throughout their careers, and 13.3% had experienced it within the past year16.

In Argentina, most professionals who experienced the SV phenomenon prioritized communicating the AE to their team, patients, and family members, highlighting positive aspects. However, some reported a lack of understanding and acceptance from their supervisors17. In Chile, 90.2% of nurses working in Intensive Care Units had been involved in an AE. Among them, 65.6% reported the incident to their supervisor, 66% expressed feelings of guilt about what happened, and 53% reported being aware of institutional support18.

A study involving Brazilian nurses revealed the group's difficulty in reporting AEs in the institution where they work due to fear of judgment and punishment, even exhibiting signs and symptoms of emotional distress19. In the same country, 54.3% of newly graduated nurses involved in AEs were unfamiliar with the term "second victim." Negative feelings (94.6%) and insecurity (70.3%) were prevalent. While the majority received support (59.5%), not all was provided through formal or institutional channels20, a situation consistent with findings from another national study21.

The training and preparation of healthcare teams to understand the SV phenomenon, along with the support offered to these professionals, are just as important as reporting errors. However, organizational culture and how leaders handle such situations have a direct impact on the reporting of AEs. These data highlight the urgent need for institutional policies aimed at mitigating this phenomenon's negative effects, which represents a critical challenge for health systems worldwide. Therefore, support strategies for healthcare professionals who experience the SV phenomenon should aim to provide emotional and psychological support, enabling their recovery and return to work.

Formal support programs and services have been developed by hospitals and educational organizations. These programs are similar because they address the SV, offering support across three levels of care. The first level involves initial contact by colleagues or coworkers as soon as possible after the occurrence of an AE. The second level consists of the support provided by professionals trained to assess whether signs of distress persist in the SV. However, if emotional distress persists, these professionals should be referred to specialized care, which may include psychologists and/or legal counselors. Examples of these programs include Peer Support from the Center for Professionalism and Peer Support (CPPS)22, Resilience in Stressful Events (RISE)23, and Medically Induced Trauma Support Services (MITSS)24.

Another support strategy refers to implementing guidelines and tools that provide recommendations to strengthen the culture of safety, develop institutional policies, and offer support to patients, healthcare professionals, and institutions following an AE. This strategy may take the form of guidelines, scripts, checklists, and algorithms25, among others. One example is the guideline developed by the Agency for Healthcare Research and Quality (AHRQ)26, used to guide managers and professionals in implementing, monitoring, and improving the Care for the Caregiver program. As a model tool, there is the Toolkit for Building a Clinician and Staff Support Program, available from MITSS27, which helps develop a culture of safety, train peer supporters, and communicate with SV. Another electronic tool is BACRA (in Spanish Basado en Análisis Causa-Raíz meaning "based on root-cause analysis")25, designed to help managers monitor healthcare-related risks of professionals affected by AEs.

The literature also describes other forms of interventions and actions to support SVs, which may be informal or formal. Informal experiences include sharing experiences with colleagues, spouses, family members, friends, or other trusted individuals23,28,29. Formal approaches involve structured dialogues with managers, mental health specialists, or experienced peers trained in this role28,30,31. In addition, problem- and emotion-focused coping strategies32,33, reflective writing30,34, temporary leave from work35,36, learning from mistakes37, and receiving positive feedback38,39 are highlighted. SVs recognize employee assistance programs14, institutional policies, and guidelines aimed at protecting the patient-professional relationship as an organizational support strategy40,41 and resort to a Second Victim Support Unit (USVIC)42, an online platform developed to strengthen communication, explain the phenomenon, and provide support for patient safety39,43.

Leadership support for SV is also critical. Leaders with more collaborative and decentralized profiles, who move away from authoritarian and hierarchical models, foster greater trust among staff, encouraging the reporting of AEs and promoting continuous improvement in care quality and patient safety44,45. Moreover, how leaders support SVs is crucial for shaping the outcome of this condition. In Finland, nurse managers recommend peer support for SVs, independent of formal management, due to the immediate proximity of colleagues when an AE occurs. Coworkers can provide this support even informally, regardless of whether they are not trained in SV response46. Empathetic leaders foster an emotionally supportive environment and establish formal and informal support mechanisms, such as counseling services and support groups, to help mitigate the emotional effects of AEs47-50.

Therefore, it is essential for healthcare institutions to adopt policies and practices that promote a culture of safety, encourage error reporting without fear of punishment, and provide appropriate emotional and psychological support to SVs. Support programs, alongside empathetic and collaborative leadership, are essential to help professionals recover from the trauma of AEs and return to work with safety and confidence. By prioritizing the well-being of healthcare professionals, we not only strengthen a just safety culture but also develop a more humane, resilient, and responsive healthcare system prepared to face the challenges inherent to medical care.

Conflicts of Interest: The authors declare no conflicts of interest.

Funding: This research did not receive external funding.

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Referencias

Seys D, Wu AW, Gerven EV, Vleugels A, Euwema M, Panella M et al. Health care professionals as second victims after adverse events: a systematic review. Eval Health Prof. 2013;36(2):135-62. https://doi.org/10.1177/0163278712458918

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Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320:726. https://doi.org/10.1136/bmj.320.7237.726

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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. Qual Saf Health Care. 2009;18(5):325-30. https://doi.org/10.1136/qshc.2009.032870

X

Referencias

Vanhaecht K, Seys D, Russotto S, Strametz R, Mira J, Sigurgeirsdóttir S, et al. An Evidence and Consensus-Based Definition of Second Victim: A Strategic Topic in Healthcare Quality, Patient Safety, Person-Centeredness and Human Resource Management. Int J Environ Res Public Health. 2022;19(24):16869. https://doi.org/10.3390/ijerph192416869

X

Referencias

Busch IM, Moretti F, Purgato M, Barbui C, Wu AW, Rimondini M. Psychological and Psychosomatic Symptoms of Second Victims of Adverse Events: A Systematic Review and Meta-Analysis. J Patient Saf. 2020;16(2):e61-e74. Erratum. J Patient Saf. 2020;16(3):e211. https://doi.org/10.1097/PTS.0000000000000779

X

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Treiber LA, Jones JH. Devastatingly Human: An Analysis of Registered Nurses’ Medication Error Accounts. Qual Health Res. 2010;20(10):1327–1342. https://doi.org/10.1177/1049732310372228

X

Referencias

Cohen R, Sela Y, Hochwald IH, Nissanholz-Gannot R. Nurses' Silence: Understanding the Impacts of Second Victim Phenomenon among Israeli Nurses. Healthcare (Basel). 2023;11(13):1961. https://doi.org/10.3390/healthcare11131961

X

Referencias

Harrison R, Lawton R, Stewart K. Doctors' experiences of adverse events in secondary care: the professional and personal impact. Clin Med. 2014;14(6):585-90. https://doi.org/10.7861/clinmedicine.14-6-585

X

Referencias

Strametz R, Koch P, Vogelgesang A, Burbridge A, Rösner H, Abloescher M, et al. Prevalence of second victims, risk factors and support strategies among young German physicians in internal medicine (SeViD-I survey). J Occup Med Toxicol. 2021;16. https://doi.org/10.1186/s12995-021-00300-8

X

Referencias

Krommer E, Ablöscher M, Klemm V, Gatterer C, Rösner H, Strametz R, et al. Second Victim Phenomenon in an Austrian Hospital before the Implementation of the Systematic Collegial Help Program KoHi: A Descriptive Study. Int J Environ Res Public Health. 2023;20(3):1913. https://doi.org/10.3390/ijerph20031913

X

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Neyens L, Stouten E, Vanhaecht K, Mira J, Panella M, Seys D, et al. Open Disclosure Among General Practitioners as Second Victim of a Patient Safety Incident: A Cross-Sectional Study in Flanders (Belgium). J Patient Saf. 2025;21(1):9-14. https://doi.org/10.1097/PTS.0000000000001299

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Mira JJ, Carrillo I, Lorenzo S, Ferrús L, Silvestre C, Pérez-Pérez P, et al. The aftermath of adverse events in Spanish primary care and hospital health professionals. BMC Health Serv Res. 2015;15. https://doi.org/10.1186/s12913-015-0790-7

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>Institute for Safe Medication Practices Canada - ISMP. Second victim: Sharing the Journey toward Healing. ISMP Canada Safety Bulletin. 2017;17(9):1-6. https://ismpcanada.ca/wp-content/uploads/ISMPCSB2017-10-SecondVictim.pdf

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Johnson TN, Tucker AM. Pharmacy prevalence of second victim syndrome in a comprehensive cancer center. Am J Health-Sys Pharm. 2024;82(6):297-305. https://doi.org/10.1093/ajhp/zxae267

X

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Rivera-Chiauzi E, Finney RE, Riggan KA, Weaver AL, Long ME, Torbenson VE, et al. Understanding the second victim experience among multidisciplinary providers in OBGYN. J Patient Saf. 2022;18(2):e463–e469. https://doi.org/10.1097/PTS.0000000000000850

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Brunelli MV, Seisdedos MG, Martinez MM. Second Victim Experience: A Dynamic Process Conditioned by the Environment. A Qualitative Research. Int J Public Health. 2024;69:1607399. https://doi.org/10.3389/ijph.2024.1607399

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Kappes M, Delgado-Hito P, Contreras VR, Romero-García M. Prevalence of the second victim phenomenon among intensive care unit nurses and the support provided by their organizations. Nurs Crit Care. 2023;28(6):1022-1030. https://doi.org/10.1111/nicc.12967

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Silveira SE, Tomaschewski-Barlem JG, Tavares APM, Paloski G do R, Feijó G dos S, Cabral CN. Impacts of patient safety incidents on nursing: a look at the second victim. Rev enferm UERJ. 2023;31(1):e73147. http://dx.doi.org/10.12957/reuerj.2023.73147

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References

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  2. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320:726. https://doi.org/10.1136/bmj.320.7237.726

  3. 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. Qual Saf Health Care. 2009;18(5):325-30. https://doi.org/10.1136/qshc.2009.032870

  4. Vanhaecht K, Seys D, Russotto S, Strametz R, Mira J, Sigurgeirsdóttir S, et al. An Evidence and Consensus-Based Definition of Second Victim: A Strategic Topic in Healthcare Quality, Patient Safety, Person-Centeredness and Human Resource Management. Int J Environ Res Public Health. 2022;19(24):16869. https://doi.org/10.3390/ijerph192416869

  5. Busch IM, Moretti F, Purgato M, Barbui C, Wu AW, Rimondini M. Psychological and Psychosomatic Symptoms of Second Victims of Adverse Events: A Systematic Review and Meta-Analysis. J Patient Saf. 2020;16(2):e61-e74. Erratum. J Patient Saf. 2020;16(3):e211. https://doi.org/10.1097/PTS.0000000000000779

  6. Treiber LA, Jones JH. Devastatingly Human: An Analysis of Registered Nurses’ Medication Error Accounts. Qual Health Res. 2010;20(10):1327–1342. https://doi.org/10.1177/1049732310372228

  7. Cohen R, Sela Y, Hochwald IH, Nissanholz-Gannot R. Nurses' Silence: Understanding the Impacts of Second Victim Phenomenon among Israeli Nurses. Healthcare (Basel). 2023;11(13):1961. https://doi.org/10.3390/healthcare11131961

  8. Harrison R, Lawton R, Stewart K. Doctors' experiences of adverse events in secondary care: the professional and personal impact. Clin Med. 2014;14(6):585-90. https://doi.org/10.7861/clinmedicine.14-6-585

  9. Strametz R, Koch P, Vogelgesang A, Burbridge A, Rösner H, Abloescher M, et al. Prevalence of second victims, risk factors and support strategies among young German physicians in internal medicine (SeViD-I survey). J Occup Med Toxicol. 2021;16. https://doi.org/10.1186/s12995-021-00300-8

  10. Krommer E, Ablöscher M, Klemm V, Gatterer C, Rösner H, Strametz R, et al. Second Victim Phenomenon in an Austrian Hospital before the Implementation of the Systematic Collegial Help Program KoHi: A Descriptive Study. Int J Environ Res Public Health. 2023;20(3):1913. https://doi.org/10.3390/ijerph20031913

  11. Neyens L, Stouten E, Vanhaecht K, Mira J, Panella M, Seys D, et al. Open Disclosure Among General Practitioners as Second Victim of a Patient Safety Incident: A Cross-Sectional Study in Flanders (Belgium). J Patient Saf. 2025;21(1):9-14. https://doi.org/10.1097/PTS.0000000000001299

  12. Mira JJ, Carrillo I, Lorenzo S, Ferrús L, Silvestre C, Pérez-Pérez P, et al. The aftermath of adverse events in Spanish primary care and hospital health professionals. BMC Health Serv Res. 2015;15. https://doi.org/10.1186/s12913-015-0790-7

  13. >Institute for Safe Medication Practices Canada - ISMP. Second victim: Sharing the Journey toward Healing. ISMP Canada Safety Bulletin. 2017;17(9):1-6. https://ismpcanada.ca/wp-content/uploads/ISMPCSB2017-10-SecondVictim.pdf

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  15. Johnson TN, Tucker AM. Pharmacy prevalence of second victim syndrome in a comprehensive cancer center. Am J Health-Sys Pharm. 2024;82(6):297-305. https://doi.org/10.1093/ajhp/zxae267

  16. Rivera-Chiauzi E, Finney RE, Riggan KA, Weaver AL, Long ME, Torbenson VE, et al. Understanding the second victim experience among multidisciplinary providers in OBGYN. J Patient Saf. 2022;18(2):e463–e469. https://doi.org/10.1097/PTS.0000000000000850

  17. Brunelli MV, Seisdedos MG, Martinez MM. Second Victim Experience: A Dynamic Process Conditioned by the Environment. A Qualitative Research. Int J Public Health. 2024;69:1607399. https://doi.org/10.3389/ijph.2024.1607399

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