Supporting healthcare individuals and teams after an adverse event: the care for the second victim (Staender)

Work in anaesthesia and the peri-operative setting takes place in a complex and dynamic environment. Decisions often have to be made under time pressure and not all the information necessary for the decision-making process is always available. Accordingly, it is important for patient safety that the necessary technology is available, that sufficient resources exist, that processes are clarified and that well trained personnel work in these areas, with as little stress as possible.

Nevertheless, despite the best conditions, there will, unfortunately always be avoidable errors in patient treatment because the healthcare system is highly complex, conditions are rarely optimal and even the best specialists can never work without errors. The rate of avoidable errors and corresponding harm in medicine is substantial and continues to be high.219 This primarily affects the patients and their relatives, who are accordingly referred to as ‘first victims’. But also, the employees involved in the incorrect treatment suffer to an often not inconsiderable extent from the event and are referred to as ‘second victims’.360 The effects on these ‘second victims’ can be considerable. Taking into account that physicians are bound by the edict ‘Primum non nocere’ (first, do no harm), any harm to patients due to actions of the healthcare provider shakes the fundamentals on which physicians practice. Fear, feelings of guilt or self-doubt can be the consequences of treatment errors for the persons involved. In the extreme, experiencing somatic symptoms, medication or drug abuse, thoughts of giving up one’s job, thoughts of suicide or even committing suicide have been described.361–367 Williams et al.368 showed that stressed and burned-out physicians reported a greater likelihood of making errors and mentioned more often suboptimal patient care. A study involving internal medicine residents showed that higher levels of fatigue and distress were independently associated with self-perceived medical errors.369 An increased error-rate in depressed residents in paediatrics and a comparable phenomenon in nurses has been shown before.370,371 This means that the ‘second victim’ is not only an individual problem for the healthcare provider involved, but also for safety in general. The question to address must be first of all how to avoid medical error, and second how to support those that suffer after having been involved in a medical error. The overall extent of that problem is not that well documented. A study in anaesthesiology from 2012 found that, in their career, 85% of the respondents reported having been involved in at least one unanticipated death or serious harm to a peri-operative patient.362

Considering the significance of the ‘second victim’ problem, the question arises how to deal best with this phenomenon to minimise the consequences for the employees involved. Healthcare professionals can be affected by a treatment error in different ways; first, by the experience of the treatment error itself; and second, by the way in which they were treated themselves after such an event happened.365 It is important to address these aspects not only at the individual level, but also institutionally. Burlison et al.367 showed that an adequate response by the organisation to the needs of ‘second victims’ has a positive effect on the retention of the ‘second victim’ in current employment.

What are the needs of ‘second victims’? Numerous studies demonstrated that after a treatment error happened the member of staff involved needs coping strategies and an opportunity to discuss the unwanted event with peers.372 An excellent publication on this topic made recommendations to support affected persons, including, for example, the prompt debriefing and crisis intervention for the individual and/or team involved, an opportunity to discuss any ethical concerns, as well as a safe opportunity to contribute any insights into how similar events could be prevented in the future.372 The initial debriefing should be done as quick as possible, through the most senior peer available, assuring complete confidentiality. The conversation should focus on ‘why’ and not ‘who’, and should show empathy and avoid the questions of ‘guilt’.

The most important aspect from the perspective of the ‘second victim’ was the confirmation of professional competence by a peer,372 because those persons affected may have considerable self-doubt about their competence and the feedback of a peer, being able to comprehend the decision in the present case, can be extremely helpful. Conversely, there are behaviours or remarks from colleagues after a treatment error that are inappropriate or even harmful, for example, Didn’t you realise what would happen?, or What were you thinking?, or I wouldn’t have done that!.372

There is a general recommendation that organisations have a support programme in place as part of a comprehensive process for responding on an adverse event. Today, a variety of supporting programmes are described, especially in large hospitals, for example, the programme of the University of Missouri (ForYou Program) or at Johns Hopkins (RISE) in the United States.373,374 The support programme Medically Induced Trauma Support Services Toolkit is available on the Internet ( It offers not only individual support but also training programmes for nursing staff and doctors as well as assistance in the creation of organisational programmes.

There is only little research on the effects of existing support programmes: even one of the first programmes to support ‘second victims’ at Johns Hopkins Hospital (RISE) did not report a systematic follow-up of outcomes of the people involved in their programme. Nevertheless, they demonstrated a success based on the self-reports of the peers involved. Especially, the training programme as part of that initiative to support peers dealing with ‘second victims’ was reported to be successful.373


Healthcare professionals confronted to having made an error leading to patient harm suffer from that error, being a ‘second victim’. This effect has different degrees of expression but can lead to severe impairment of the healthcare professional, which again could promote further errors happening in future treatment by the respective professionals. When dealing with these ‘second victims’, one of the most important aspects is an early debriefing, emotional support and the opportunity to discuss the events that happened with peers. There is a general recommendation to have programmes in place at the organisational level to support these professionals and to make it easier to break the wall of silence, but further research is needed to demonstrate the effect of such programmes.

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