_{Published October 25, 2021}

“My section chief called and asked me to review an oncology staging CT scan that I had read last year. It didn’t take me long to recognize that I had missed an enhancing lesion in the pancreatic head that since metastasized all over the peritoneal cavity and into the lungs. How could I have possibly missed the original mass? Did I read this case carefully? What should I do now? Should I call and talk with the referring provider? She’ll lose all confidence in my clinical skills. Should I contact the patient? What will my radiology colleagues and trainees think of me? What about my family? What about the patient’s family? Should I apologize? Do I call risk management? Will I be sued? Will the local newspapers write about this? I feel absolutely awful. What can I possibly do to help now? Is this the end of my career as a radiologist?”

This scenario is not uncommon—a medical provider, such as a radiologist, can make an unintended error that becomes very consequential for the patient. Chances are, that radiologist won’t have the tools to manage the situation or know who to ask for help, which can lead them down a lonely, emotional, and difficult path. Even seemingly small errors can have a butterfly effect, magnifying and negatively impacting the patient and their loved ones at a later date, as well as the provider, their institution, and their future patients.

While we must always focus on providing the safest, most effective care to each patient, in this issue of InPractice, I want to stand up for our many so-called “second victims” [1], who were without guidance or resources when they needed them most. As we continue our theme of building and sustaining high-performing teams, there may be times when medical professionals fall victim to the many consequences of an adverse event and experience second-victim syndrome.

The term “victim” is in no way intended to protect, minimize, or excuse the event; rather, it aims to highlight that, in addition to supporting the patient and their loved ones, we need to provide and activate additional resources for our own team after an adverse event. This speaks to a desirable culture of support and learning, rather than one of blame and punishment.

What and Who Is a Second Victim?

The second victim is the health care professional who commits an unintentional error or is involved in a serious adverse event and is traumatized by the event. Let’s think beyond a radiologist who accidentally left a guidewire in during a minimally invasive procedure. Consider the technologist after a patient suffers a serious adverse contrast reaction. Or the nurse when a patient becomes aggressive, or the sonographer who has detected a fetal demise. Consider the resident who participated in a study interpretation with a missed finding that becomes untreatable. An individual or team in our profession, no matter their professional level, can be susceptible to this concept.

What Are Some of the Manifestations of Being a Second Victim?

The immediate impact can parallel an acute stress disorder or a preexisting psychological condition and may require urgent care. The impact may last weeks to months, or even longer, and include symptoms of post-traumatic stress disorder. The clinical and emotional manifestations—such as feelings of inadequacy, shame, guilt, anxiety, grief, and clinical depression—can be broad, varied, and extremely serious. Additionally, an individual’s physical health, sleep, work performance, and relationships can suffer greatly during this period. For health care workers, clinical confidence may be affected, as well as self-esteem and cognitive function, thus interfering with their ability to provide safe care to other patients.

Why Is This Phenomenon Increasingly Recognizable?

It is now widely acknowledged that health care workers can be significantly impacted by adverse patient events. The rate of adverse outcomes, errors, or complications is not actually increasing, though; our willingness to report and speak up safely about errors is. This, coupled with greater regulatory oversight (such as auditing for compliance with national patient safety goals), creates a natural and rather awkward tension between the desire to collectively learn and improve from errors, and the desire to protect individuals and teams and avoid the medical, legal, and institutional consequences of an adverse event. Growing peer learning practices, along with the expansion of disclose, apology, and offer programs, are likely contributing to this tension, too.

How Can We Support Second Victims?

The focus on stress, burnout, and wellness may have contributed to the growing awareness of second victims. This is a chicken and egg phenomenon—somebody who experiences stress or burnout in the workplace is more likely to make an error. When errors occur, these contribute to stress and perhaps even to burnout. In both circumstances, recognizing that a problem exists, providing appropriate support to the individuals involved, and offering training programs [2] to deliver such support is critical.

To create change, we must begin at the local level and educate our leaders and peers about how to anticipate and recognize the signs and symptoms of anxiety and other psychological conditions—both within ourselves and others. When things go wrong, as they will, all practices must have a dedicated team or process in place that first takes care of the patient, then oversees peer support for additional victims, while managing risk, regulatory, and compliance components.

I cannot advocate strongly enough for effective peer support programs, though not all victims will access available support services for fear of consequences, or for fear of being considered weak or vulnerable. These services must be confidential and readily available. Peer support programs can address both the emotional and informational aspects:

• How is the patient doing?
• What is happening?
• What will happen?
• What might happen?

Peer support may expand to counseling, including providing time and space and ongoing support for healing. Chances are, your institution or practice has an employee assistance program that includes several of these resources. It’s up to us to share them and encourage our teams and colleagues to seek the support that they need [3].

As physicians, we must remember that we are both human and fallible. Where we can improve is by learning from our errors and near-misses and sharing these lessons widely with the participation and support of our leaders within a culture of no blame.

Notes

• There are growing calls to abandon the term “second victim.” Instead, patient advocates are asking that health care professionals and institutions break down barriers and take more responsibility by engaging with patients, families, and advocacy organizations to understand more broadly how everyone is affected by medical harm.
• Caring for the caregiver: the RISE program. Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine website.
• If you or someone you know is experiencing a psychological crisis, you are not alone. Call 911 or go to the nearest emergency room. You can also call the National Suicide Prevention Lifeline at 800-273-TALK (8255) to speak with a trained crisis counselor 24/7 or text NAMI to 741-741 to connect with a trained crisis counselor to receive crisis support via text message 24/7.