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PSNet: Patient Safety Network
Journal Article

Suffering in silence: a qualitative study of second victims of adverse events.

Ullström S, Sachs MA, Hansson J, et al. BMJ quality & safety. 2014;23:325-31.

Clinicians who are involved in a medical error experience considerable emotional distress, shame, and self-doubt, and the term "second victim" reflects these effects. This qualitative study provides vivid examples of the second victim phenomenon in 21 health care professionals (primarily doctors and nurses) who were involved in errors at a Swedish hospital. Interviews with the affected clinicians revealed that the immediate emotional effects were compounded by a lack of institutional support in the weeks to months after the incident. In response to these issues, some hospitals have instituted structured approaches, such as a second victim rapid response team, to provide a non-judgmental sounding board and debriefing opportunity for affected providers after serious medical errors. Dr. Albert Wu, who coined the term second victim and has extensively researched this phenomenon, was interviewed by AHRQ WebM&M in 2011.