Medical Errors and the “Second Victim” Phenomenon in the Healthcare System: Implications for Patient Safety and Health Policy

Anna Gawrońska

doi:10.21697/ejhp.0112.04

Published: 2026-06-30

Vol. 6 No. 1 (2026)

Medical Errors and the “Second Victim” Phenomenon in the Healthcare System: Implications for Patient Safety and Health Policy

Anna Gawrońska

European Journal of Health Policy, Humanization of Care and Medical Ethics

Section: Articles

https://doi.org/10.21697/ejhp.0112.04

Abstract

The second victim phenomenon refers to the emotional, psychological, and professional consequences for healthcare personnel after being involved in an adverse event. Although this concept was described more than two decades ago, it remains one of the most underestimated areas of patient safety. This article provides an indepth narrative synthesis of research on healthcare workers’
experiences, analyzes organizational and systemic consequences, and identifies directions for health policy action. Particular emphasis is placed on organizational culture, support models, and barriers to implementation. The discussion and conclusions are combined to present the second victim phenomenon as a key indicator of the overall condition of the healthcare system.

Keywords:

second victim phenomenon, support program, emotional and psychological reaction, healthcare worker, moral injury

Download files

pdf

Cited by / Share

Licence

References

Busch, I. M., Moretti, F., Purgato, M., & Barbui, C. (2020). Psychological and psychosomatic symptoms of second victims of adverse events: a systematic review and meta-analysis. Journal of Patient Safety, 16(2), e61–e74. DOI: https://doi.org/10.1097/PTS.0000000000000589
Google Scholar

Conway, J., Federico, F., Stewart, K., & Campbell, M. (2011). Respectful management of serious clinical adverse events. Institute for Healthcare Improvement.
Google Scholar

Dean, W., Talbot, S., & Dean, A. (2019). Reframing clinician distress: Moral injury not burnout. The Lancet, 393(10177), 110–111.
Google Scholar

Dekker, S. (2011). Drift into failure: From hunting broken components to understanding complex systems. Ashgate.
Google Scholar

Denham, C. R. (2007). TRUST: The 5 rights of the second victim. Journal of Patient Safety, 3(2), 107–119. DOI: https://doi.org/10.1097/01.jps.0000236917.02321.fd
Google Scholar

Edmondson, A. (2019). The fearless organization: Creating psychological safety in the workplace for learning, innovation, and growth. Wiley.
Google Scholar

Edrees, H., Connors, C., Paine, L., Norvell, M., Taylor, H., & Wu, A. W. (2016). Implementing the RISE second victim support programme at the Johns Hopkins Hospital: A case study. BMJ Open, 6(9), e011708. DOI: https://doi.org/10.1136/bmjopen-2016-011708
Google Scholar

Gallagher, T. H ., Waterman, A. D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003). Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA, 289(8), 1001–1007. DOI: https://doi.org/10.1001/jama.289.8.1001
Google Scholar

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S . (Eds.). (2000). To err Is human: Building a safer health system. National Academy Press.
Google Scholar

Kowalska, M., et al. (2022). Safety culture and support needs among healthcare workers after adverse events in Poland. International Journal for Quality in Health Care, 34(3), mzac012.
Google Scholar

Leape, L. L. (2015). Errors in medicine. Clinical Orthopaedics and Related Research, 473(5), 1382–1389. DOI: https://doi.org/10.1007/s11999-014-3598-6
Google Scholar

Makary, M. A., & Daniel, M. (2016). Medical error-the third leading cause of death in the US. BMJ, 353, i2139. DOI: https://doi.org/10.1136/bmj.i2139
Google Scholar

Moran, D., Wu, A. W., Connors, C., & Padula, W. V. (2021). Cost-benefit analysis of a support program for second victims in healthcare. Journal of Patient Safety, 17(8), e1571–e1577.
Google Scholar

NHS Improvement. (2018). A just culture guide. National Health Service.
Google Scholar

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768–770. DOI: https://doi.org/10.1136/bmj.320.7237.768
Google Scholar

Scott, S. D., Hirschinger, L. E., Cox, K. R ., McCoig, M., Brandt, J., & Hall, L. W . (2009). The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Quality and Safety in Health Care, 18(5), 325–330. DOI: https://doi.org/10.1007/978-0-387-92853-1_28
Google Scholar

Scott, S. D., et al. (2010). Caring for our own: Deploying a systemwide second victim rapid response team. Joint Commission Journal on Quality and Patient Safety, 36(5), 233–240. DOI: https://doi.org/10.1016/S1553-7250(10)36038-7
Google Scholar

Senge, P. (2006). The fifth discipline: The art and practice of the learning organization. Doubleday.
Google Scholar

Seys, D., et al. (2013). Health care professionals as second victims after adverse events: A systematic
Google Scholar

review. Evaluation & the Health Professions, 36(2), 135–162.
Google Scholar

Van Gerven, E., et al. (2016). Increased risk of burnout for physicians and nurses involved in a patient safety incident. Medical Care, 54(10), 937–943. DOI: https://doi.org/10.1097/MLR.0000000000000582
Google Scholar

Vincent, C. (2010). Patient safety. Wiley-Blackwell. DOI: https://doi.org/10.1002/9781444323856
Google Scholar

Waterman, A. D., Garbutt, J., Hazel, E., Dunagan, W. C., Levinson, W., & Gallagher, T. H. (2007). The emotional impact of medical errors on practicing physicians in the United States and Canada. Joint Commission Journal on Quality and Patient Safety, 33(8), 467–476. DOI: https://doi.org/10.1016/S1553-7250(07)33050-X
Google Scholar

Williamson, V., Murphy, D., & Greenberg, N. (2020). COVID-19 and experiences of moral injury in frontline key workers. Occupational Medicine, 70(5), 317–319. DOI: https://doi.org/10.1093/occmed/kqaa052
Google Scholar

Wu, A. W. (2000). Medical error: The second victim. BMJ, 320(7237), 726–727.
Google Scholar