Intended for healthcare professionals

Rapid response to:


Supporting clinicians after medical error

BMJ 2015; 350 doi: (Published 15 April 2015) Cite this as: BMJ 2015;350:h1982

Rapid Response:

Supporting "second victims" is a system-wide responsibility

The “second victim” phenomenon can be devastating for individual clinicians, but it also has serious implications for patient safety and safety culture, so responsibility for recognizing and addressing it goes well beyond individual clinicians and their employing organizations.

“Second victim” experiences are directly affected by the manner in which incidents are dealt with and investigations conducted; they will be worse in clinicians who have negative experiences of investigations or who feel that they have been dealt with in a punitive manner. Such clinicians become less likely to report future incidents or to practice transparently, and if they are senior then their attitudes will influence the behavior of more junior staff (1).

A Royal College of Physicians survey of 1755 senior NHS physicians reinforces findings of previous work in other groups (2). Most had been involved in serious adverse events and most had experienced the sorts of “second victim” effects described by Edrees and Federico; 60-75% described sleep disturbance, anxiety or stress and a small but significant percentage described effects similar to Post Traumatic Stress Disorder. Although most had used formal incident reporting systems only a minority described positive feedback or useful learning; 25% admitted being involved in incidents which they knew they should have reported, but didn’t. Factors contributing to this included a belief that nothing would change as a result of reporting, fear of punitive action and the psychological effects of having been involved in a previous adverse event.

Few physicians have formal sources of support after incidents; most turn to friends and colleagues as only 5% have a formal mentor. However, 80% of respondents describe a determination to improve as a result of an adverse event suggesting that in the right circumstances they could be engaged in a learning process.

The NHS is still a long way from the open, transparent, safety culture that we need (3) and this will only be achieved if we recognize and address the “second victim” phenomenon. We would caution against characterizing this as only due to “clinicians unable to cope with their emotions after a medical error” although we recognize the importance of providing support, including mentoring, to individual clinicians. However, since the attitude and behavior of policymakers, regulators, those managing reporting systems and other external bodies can be part of the problem then these bodies must also take responsibility for being part of the solution.

1. Sirriyeh R, Lawton RJ, Gardner P. et al. Coping with medical error: A systematic review of papers to assess the effects of involvement in medical error on health care professional’s psychological well-being. Qual Saf Health Care 2010; 19: 1-8.
2. Harrison R, Lawton R, Stewart K. Doctors’ experiences of adverse events in secondary care; the professional and personal impact. Clinical Medicine 2014 Vol 14, No 6 (Dec 2014) 585-90.
3. National Advisory Group on the Safety of Patients in England. A promise to learn—a commitment to act. Department of Health, 2013.

Competing interests: No competing interests

21 April 2015
Kevin Stewart
Clinical Director, Clinical Effectiveness & Evaluation Unit
Reema Harrison, Rebecca Lawton
Royal College of Physicians
11 St Andrew's Place, London NW1 4LE