Department: Editor's Memo
I was immediately stricken by the "second-victim" phenomenon when the news of Kimberly Hiatt, the intensive care nurse who committed suicide after overdosing an infant in her care, hit the media. The subsequent death of the critically ill infant, however, could not be linked to the nurse's actions. Reports from family and friends indicated that Kimberly's psychological well-being progressively deteriorated during the months following the infant's death; her despair and loss of hope to ever practice as a nurse again were presumed to be the reasons she took her own life. As her mother said in a recent article, "She ran out of coping skills."1
The "other" victim
With medical errors, there is often more than one victim. The first victim is the individual who suffers injury or death, and the second is the care provider who made the mistake leading to the adverse or fatal outcome. In an editorial, Dr. A.W. Wu noted, "Even when mistakes are discussed at morbidity and mortality conferences, it is to examine the medical facts rather than the feelings of the patient or physician."2 He also acknowledged that other members of the healthcare team, including nurses, are just as vulnerable as physicians to becoming the second victim of a medical error. Providers may begin to doubt their competency to perform duties, question their judgment and aptness for the chosen profession, or experience conflicting instincts about being truthful about the error in a sometimes unfriendly work environment, fearful of the reactions of employers and colleagues.
A long road to recovery
Scott et al.3 interviewed past second victims from different professions to determine their experiences and recovery trajectory. Their research was aimed at helping institutions develop appropriate support strategies that would guide second victims to quicker recoveries and avert adverse career outcomes. The report demonstrates methodological rigor in implementing and analyzing data from this qualitative study. Researchers identified and described six stages of recovery for second victims: (1) chaos and accident response; (2) intrusive reflections; (3) restoring personal integrity; (4) enduring the inquisition; (5) obtaining emotional first aid; and (6) moving on–dropping out, surviving, or thriving. The sixth stage seemed to be the most critical in determining the ultimate outcome—whether the individual left the profession, returned to provide the previous standard of care, or returned with newfound insight and conviction.
The authors, however, do not introduce the idea of another possible category in Stage 6—"not moving on," as was the case for Kimberly Hiatt. Recommendations included the need to raise institutional awareness about second victims and establish immediate surveillance and support for them. In the Hiatt case, lack of full disclosure surrounding her dismissal has created controversy over how the hospital handled the medical error. Employers are bound by certain rules, however, and the public is not always entitled to the details of every story.
An ongoing problem
I will wager that most healthcare professionals have been involved in at least one medical error, even if it was minor. I further presume that attention was given first to the error, then the patient, and then the person who made the error. All errors do not result in harm. Twelve years after the Institute of Medicine's report, To Err is Human: Building a Safer Health System, we still struggle to correct faulty systems, processes, and conditions that set the stage for errors. We made huge strides to ensure patient safety and reduce medical errors, but a lot more work needs to be done at the systems level, especially for the second victim of a medical error.
Jamesetta Newland, PhD, RN, FNP-BC, FAANP, FNAP
3. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider "second victim" after adverse patient events. Qual Saf Health Care
. 2009;18(5):325–330. doi:10.1136/qshc.2009.032870.