Defining the second victim
The term ‘second victim’was first introduced by Albert Wu in 2000 to describe health and care professionals who experience emotional distress after being involved in an adverse event that affects their patients [1]. This phenomenon has been widely studied in recent years, leading to a better understanding of the emotional response, prevalence, and trajectory of second victims [2,3]. Additionally, research has promoted structured support mechanisms aimed at mitigating its negative effects on professional well-being, patient safety, and organizational culture [4,5]. More recently, the European Researchers’ Network Working on Second Victims (ERNST) has expanded this definition [6], recognizing that healthcare professionals frequently face highly stressful situations that limit their ability to respond effectively. ERNST highlights the need for resilience as an essential competence for daily clinical practice.
The second victim experience is typically characterized by self-doubt, anxiety, and guilt, often accompanied by shame and embarrassment, as professionals may feel a deep sense of personal failure and humiliation [3]. Many also experience fear of repercussions, worrying about potential legal, professional, or reputational consequences. Additionally, second victims frequently suffer from sleep disturbances, such as insomnia or nightmares related to the adverse event, as well as intrusive thoughts, with persistent and distressing memories of what occurred. Over time, the accumulated stress can lead to emotional exhaustion, increasing the risk of burnout and impacting both personal well-being and professional performance. In severe cases, when these symptoms remain unaddressed or are exacerbated by a lack of support, they may progress to post-traumatic stress disorder (PTSD), further affecting the individual’s ability to function effectively in their role. Without an adequate support system, affected professionals may develop defensive medicine practices, experience reduced performance, and even consider leaving the profession. To address this issue, various approaches have been proposed, ranging from peer support programs to institutional strategies aimed at fostering a culture of safety and learning [7].
How common are the second victims?
Although the term second victim may not be widely recognized among health and care professionals, nearly all workers in the field can relate to the experience. Studies conducted in the United States, Canada, South Korea, Latin America, and Europe indicate that between 65% and 90% of health and care professionals report experiencing an emotional reaction consistent with the second victim phenomenon at some point in their careers [8,9,10,11].
This issue extends beyond seasoned professionals to medical residents, interns, and students in healthcare disciplines. Research shows that between 34% and 72% of medical residents have experienced the second victim phenomenon after being involved in an adverse event [10], with higher prevalence among those in high-intensity specialties such as emergency medicine and surgery. Additionally, up to 90% of medical and nursing students witness adverse events during their training, and 18% to 43% of those who report making errors affecting patients experience symptoms similar to those of second victims [12,13]. Despite this widespread prevalence, residents, students, and trainees alike often lack the tools and support needed to cope effectively with these situations, increasing their risk of burnout, decreased confidence, and emotional exhaustion [14]. Moreover, patient safety and the second victim phenomenon are rarely integrated into the training curricula for future health and care professionals in European faculties and medical schools [15].
Underlying causes and risk factors
The experience of second victims is shaped by several interrelated factors [7,16].
The culture of blame remains deeply ingrained in many healthcare institutions worldwide, and Europe is no exception. In these settings, errors are often viewed as individual failures rather than systemic issues, fostering a punitive environment that discourages open communication. This not only prevents healthcare professionals from seeking support but also hinders the implementation of effective preventive measures, ultimately compromising both staff well-being and patient safety.
Societal and legal frameworks, based on a conceptualization that fails to acknowledge the existence of honest mistakes arising from the inherent uncertainty and complexity of healthcare, contribute to a punitive culture. This legal gap reinforces fear, encourages avoidance behaviors, and promotes a defensive approach to clinical practice, rather than fostering an environment focused on learning, improvement, and patient safety.
The absence of a psychologically safe environment, where professionals feel they can speak up without fear of isolation or punishment, fosters anxiety and avoidance behaviors. A lack of open dialogue about errors and opportunities for improvement not only limits learning but also increases the risk of future mistakes with potentially severe consequences.
Despite international recommendations, comprehensive training in resilience is still not integrated into healthcare curricula. As a result, professionals enter the workforce without the necessary skills to manage the emotional and ethical challenges associated with the highly stressful events that characterize clinical practice.
Many institutions do not acknowledge the second victim phenomenon, and among those that do, many have not implemented structured interventions, while others have done so inconsistently. As a result, numerous healthcare professionals are left without the necessary resources to effectively cope with the emotional impact of adverse events.
Impact on patients and healthcare systems
Second victims often experience a decline in professional performance, which increases the risk of additional errors and perpetuates a cycle of psychological distress [16]. Without proper intervention, affected professionals may adopt ineffective coping mechanisms such as isolation or hypervigilance, further impairing their ability to deliver safe and high-quality care.
The second victim phenomenon also places a considerable economic burden on health and care systems. The absence of structured support programs often results in affected professionals taking medical leave, leading to productivity losses and increased operational costs for healthcare institutions. A recent estimation in Germany found that absenteeism due to the second victim phenomenon generates approximately 1.56 billion euros in lost productivity among physicians and 1.87 billion euros among nurses every year, highlighting the urgent need for institutional support programs to mitigate these impacts [17].
Mitigating the impact
ERNST has proposed a comprehensive five-phase model [18] to address the second victim phenomenon, integrating both preventive and support strategies:
- Prevention. Identifying risk factors, fostering resilience, and raising awareness about sources of distress and typical emotional responses. This also includes promoting the implementation of Just Culture principles within health and care organizations to foster a supportive, non-punitive approach to errors, enabling learning and continuous improvement in patient safety.
- Self-care. Encouraging proactive coping strategies that empower health and care professionals to independently manage the emotional impact of adverse events.
- Organized peer support. Establishing structured assistance from trained colleagues, drawing on evidence from Scott’s three-stage intervention (ForYOU) [19] and RISE (Resilience in Stressful Events) [20], to ensure that affected professionals receive immediate, empathetic, and contextually relevant support. Today in Europe, there are also well-developed peer support frameworks organized by individual institutions, networks of healthcare organizations, and professional associations, further strengthening the availability and accessibility of assistance for second victims. Currently, thanks to COST, RESCUE is developing a certification system to recognize the validity and adequacy of second victim support programs in Europe across hospitals, primary care, and nursing homes. Data demonstrates the substantial economic benefit of such interventions, as the cost savings generated by reducing the impact of the second victim phenomenon could effectively finance these support programs and preventive actions in practice.
- Structured professional support. Facilitating access to psychiatrists, clinical psychologists, or trauma counselors within the healthcare institution to provide specialized care for affected professionals.
- External professional support. Ensuring referral to external mental health services for cases where symptoms of post-traumatic stress, anxiety, or depression persist, requiring long-term intervention beyond the institutional setting.
Initially designed by ERNST, Figure 1 presents a conceptual model of quality loss due to the second victim phenomenon and illustrates how the lack of intervention to mitigate its impact ultimately leads to a deterioration in healthcare quality and a reduced ability of professionals to cope with the daily demands of clinical practice [7,18,21,22].
ERNST recommendations
ERNST emphasizes the need for a comprehensive and coordinated approach to mitigate the impact of the second victim phenomenon. Key actions include: [4]
Raising awareness among all stakeholders at European, national, and regional levels to foster discussion on the legal, ethical, social, and organizational barriers that hinder effective strategies to reduce the negative impact of the second victim phenomenon. This includes advocating for policies that promote a supportive and non-punitive culture within healthcare.
Expanding the focus beyond healthcare professionals, acknowledging that other workers in health and care institutions, also experience emotional distress and psychological reactions when exposed to stressful situations. These groups should also be included in support and intervention programs.
Promoting shared responsibility, ensuring that second victim support is not solely the concern of health and care organizations but a broader societal issue. Effective management requires coordinated action from health authorities, institutions, professional associations, patient advocacy groups, and policymakers at both national and international levels. Their efforts should be informed by scientific evidence and best practices to build a safer and more resilient health and care systems.