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Second victims’ symptoms and needs

Busch et al1 conducted a systematic review and meta-analysis to quantify the negative impacts of adverse events on the providers involved. The most prevalent symptoms found were:

In another study, the same authors also have identified the coping strategies that are applied by the second victims.2 They divided the strategies found into task-oriented, emotion-oriented and avoidance-oriented; the former includes the most frequent strategies found, and the later includes the least-frequently used strategies. Some examples are presented below:


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Second victims’ coping strategies – examples and frequency. (*) – strategy both task oriented and emotion oriented. Adapted from Busch IM, Moretti F, Purgato M, Barbui C, Wu AW, Rimondini M. Dealing With Adverse Events : A Meta-analysis on Second Victims ’ Coping Strategies. J Patient Saf. 2020;16(2):51–60.

In a qualitative exploratory study Scott et al 3 identified the stages of the history of recovery of a second victim. A second victim could pass by the first three stages simultaneously:

The trajectory of recovery for the second victims. Adapted from 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 Heal Care. 2009;18:325–30.

Stage 1: Chaos and intrusive response
Realization about what had occurred.
Frequently distracted in self-reflection while trying to manage a patient in crisis.
How did that happen?
Why did that happen?
Stage 2: Intrusive reflections
Re-evaluate scenario
Feelings of internal inadequacy and periods of self-isolation
What did I miss?
Could this have been prevented?
Stage 3: Restoring personal integrity
Seeking support of a trusty individual (colleague, family, etc)
Managing gossipFear is prevalent
What will others think?
Will I ever be trusted again?
How much trouble am I in?
How come I can’t concentrate?
Stage 4: Enduring the inquisition
Realization of level of seriousness
Respond to multiple ‘‘why’s’’ about the event
Understanding event disclosure to patient/family
Physical and psychosocial symptoms
How do I document?
Who can I talk to? 
What happens next? 
Will I lose my job/license?
How much trouble am I in?
Stage 5: Obtaining emotional first aid
Seek personal/professional support
Getting/receiving help/support
Litigation concerns emerge
Why did I respond in this manner? 
What is wrong with me? 
Do I need help?
Where can I turn for help?
Stage 6: Moving on (one of three trajectories chosen)
Dropping out: Transfer to a different unit, considering quitting, feelings of inadequacyIs this the profession I should be in?
Can I handle this kind of work?
Surviving: Coping, but still have intrusive thoughts
Persistent sadness, trying to learn from event
How could I have prevented this from happening? 
Why do I still feel so badly/guilty?
Thriving Maintain life/work balance.
Gain insight/perspective.
Does not base practice/work on one event.
Advocates for patient safety initiatives
What can I do to improve our patient safety?
What can I learn from this?
What can I do to make it better?

Three potential paths were described – dropping out, surviving, and thriving -, representing different experiences and career outcomes to the healthcare workers. 

In another study4, second victim distress has been associated with absenteeism and turnover intentions. It was found that the organizational support may result in a decrease of second victim’s distress, mediating the relationships between distress-absenteeism and distress-turnover intentions. Thus, the healthcare organizations could have an important role in the outcomes of a second victim experience and should take care of the caregiver.

What second victim needs:

  • Talk about what happened. Understand why it happened.
  • Know what to say and who to talk to.
  • Not feel rejected by colleagues, and bosses.
  • Emotional rest, cannot continue his/her work that same day.
  • Feeling useful helps the mistake never happens again.
  • Legal advice.
  • Information about the incident investigation.

What second victim DO NOT needs

  • To face a blaming attitude and rejection by colleagues and bosses.
  • To be a target of rumors.
  • Advices to not to talk about the incident and to not to notify.
  • To feel that the emotional needs are ignored.
  • To feel isolated.
  • To be subject of repeated interrogations.

  1. 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):E61–74. 
  2. Busch IM, Moretti F, Purgato M, Barbui C, Wu AW, Rimondini M. Dealing With Adverse Events : A Meta-analysis on Second Victims ’ Coping Strategies. J Patient Saf. 2020;16(2):51–60. 
  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 Heal Care. 2009;18:325–30. 
  4. Burlison JD, Quillivan RR, Scott SD, Johnson S, Hoffman JM. The Effects of the Second Victim Phenomenon on Work-Related Outcomes: Connecting Self-reported Caregiver Distress to Turnover Intentions and Absenteeism. J Patient Saf. 2021;17(3):195–9. 

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