Let the Healing Begin: Caring for the “Second Victim”

A pharmacist loses his job and his license and eventually serves time in jail for not realizing that the technician working for him used a high concentration of saline to mix a chemotherapy drug, the administration of which caused a young girl’s death. (ISMP “Eric”)

A veteran nurse makes a calculation error and delivers too much medication to an infant, which may have been a factor in the infant’s death days later. The nurse also loses her job, and the state nursing board places her on probation. She commits suicide months after the event. (ISMP “Too”)

Mistakes and adverse events such as those described above cause serious trauma to many people. Patients and their families are obviously at the center of these horrific errors, but there is a ripple effect, and at the very least, the healthcare workers directly involved in the event are often wounded. Sometimes the entire organization is affected. The healthcare industry has rightly been putting efforts toward ensuring that patients and their families receive the honest disclosure, respect, and support they deserve after these types of events.

But there is also another dimension to these events that needs to be examined, and it in no way minimizes what patients and their families should be provided in the aftermath of these errors. The previously mentioned cases briefly highlight two recent instances of well-intentioned healthcare workers who became “second victims” of adverse events. The term “second victim” was coined more than 10 years ago by Albert W. Wu, M.D., M.P.H., FACP, director of the Center for Health Services...