The second victim - supporting JMOs through medical errors

We accept the patient as the first victim, and our critical incident review process naturally focuses on their outcomes. But the health professionals who feel responsible can often be neglected.

Although linear root cause analyses attempt to appreciate the multifactorial reasons behind incidents where the individual is only one ‘hole’ in the ‘Swiss Cheese’ model, the emotional impact of errors may be overlooked. Doctors who are second victims may experience psychological distress, burnout, post-traumatic stress, risk-averse practice, and maladaptive behaviours including drug and alcohol abuse, leaving the profession and, in the worst case, suicide.

Junior doctors and trainees (JMOs) are particularly vulnerable to the effects of medical errors. Inexperience, high workload, increased fatigue, burnout, and feelings of inadequate clinical supervision are important contributors. Senior guidance is critical in shifting the perceptive from trauma to growth. Medical errors can be re-envisioned as formative learning experiences – for the second victim, their colleagues and the organisation.

Medical leadership sets the culture for how medical errors are viewed, processed and managed.

The work environment must be a safe place to discuss mistakes. Water-cooler gossip is harmful and should be actively discouraged. JMOs require support when providing open disclosure to the patient, and it helps to understand that admission and apology do not imply legal liability. They should be encouraged to have early discussions with their MDO to address medico-legal consequences.

1. Assess any acute needs. Second victims are often distressed immediately after the incident comes to light, needing a safe space for a sounding board and psychological first aid, while steering away from clinical scrutiny. The JMO may need a break or to go home. Disclosing one’s own inevitable experience of medical errors normalises and validates their experience.
2. Facilitate reflection to enable clinical growth. Have regular check-ins with the JMO and make sure they know the existing hospital and external support available for further assistance. The DRS4DRS website has many health resources. In times of crisis or distress, this website directs viewers or callers to the state-based doctors' health organisations which provide 24/7 advice lines manned by medical practitioners experienced in doctors' health. These organisations can support doctors acutely, anonymously, and with confidentiality.

Systemic change is needed when approaching medical error. When the second victim is blamed, the healthcare organisation and patients suffer. Consider what simple interventions in everyday practices could prevent future second victims, and integrate early and ongoing support for second victims into the workplace.

Open discussion of medical errors during college education, peer groups and supervision will help dispel the stigma of mistakes. At the end of the day, we are all only human. A human response of empathetic support helps JMOs become better clinicians, moving forward from ‘victim’ to formulating meaning and experience after medical error.

References available on request

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