Patient Safety Incidents: Supporting “Second Victims”

Involvement in patient safety incidents can significantly affect the professional and personal lives of the healthcare team. Therefore, it is essential they understand this “second victim” phenomenon and seek appropriate support, when necessary, to maintain resilience and achieve a healthy recovery.

A Patient Safety Incident (PSI) is defined as an incident where a patient is harmed (adverse event) or could have been harmed (near miss). A key element of managing adverse patient outcomes is providing care and support to the patient. Patients are the “first victims” and healthcare organisations and clinicians have a duty to provide them with truthful information, appropriate follow-up care and emotional support when such incidents occur.

However, there needs to be acknowledgement and understanding around the traumatic effect the incident can have on others, including clinicians and the wider healthcare team. Indeed, the staff involved in the incident may themselves become “second victims”.

Whilst it is clear that medical errors are sometimes made, it is important to highlight that not all adverse outcomes or complications are a result of a clinician’s neglect or oversight. Mr P MacDonald, colorectal surgeon, in his response to the BMJ’s Editorial Abandon the term “second victim” (2019), describes the extreme feelings and often suicidal thoughts that can occur following an adverse patient outcome from a known risk of a surgical procedure, eg, a bowel anastomosis that leaks etc.

What is a second victim?

Second Victim Support describes this phenomenon as healthcare professionals who: “are involved in an unanticipated adverse patient event, a medical error and/or a patient related injury and become victimised in the sense that the provider is traumatised 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.”

What effect does this have on clinicians?

A UK survey by Harrison R et al 2014, of fellows and members of the Royal College of Physicians was carried out to “establish physicians’ experiences of adverse patient safety events and the professional and personal impact of these”. Of the 1,463 doctors whose patients had an adverse event or near miss, 74% reported stress, 68% anxiety, 60% sleep disturbance and 63% lower professional confidence.

On a positive note, 80% of respondents reported a determination to improve following an adverse event. However, 81.5% were anxious about the potential for future errors, which the authors suggested may lead to clinicians exercising greater caution.

A clinician’s response 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 organisational response. In some cases, clinicians might experience minor stress or anxiety that dissipates in the days and weeks following an incident. Others may suffer from strong emotional reactions and symptoms akin to those of post-traumatic stress disorder, ie, second victim phenomenon.

A 2016 Italian study by Panella M et al suggested that: “Being a second victim is the strongest predictor of practising defensive medicine”.

Practising defensive medicine exposes patients to the risk of unnecessary examinations and increases the costs of care. The study also found that effective support to second victims, together with a systematic use of evidence-based clinical guidelines, resulted in possible recommendations for reducing defensive medicine.

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

Strategies to support “second victims”

By acknowledging and proactively addressing the patient safety incident-stress-error cycle, clinicians can work toward effectively managing the situation. Please refer to PMP’s accompanying Risk Tips to Support “Second Victims” which discusses these strategies.

If you are involved in a patient safety incident or receive a complaint from a patient, call the PMP medicolegal helpline as soon as possible, in line with the terms and conditions of your policy. The helpline is provided by our legal partners, Clyde & Co and is available 24/7. The number is on your customer card and your policy documents. The medicolegal helpline team can assist customers in preparing an appropriate response.