The Second Victim Experience of Nurses Involved in Medical Mistakes: Systematic Review of Referral Processes, Feasibility, and Effectiveness
Abstract
Background: The second victim syndrome is the intense emotional and professional damage caused to nurses by medical mistakes, but supporting mechanisms, particularly referral processes, are rudimentary.
Aim: This review synthesizes evidence concerning referral processes among second victim nurses, examining their feasibility, limitations, and innovations to inform fair and effective support interventions.
Methods: An integrative review was conducted searching PubMed, CINAHL, Scopus, and Web of Science (2000–2025) for peer-reviewed articles on second victim nurses. Forty sources, including qualitative, quantitative, and mixed-methods studies, were reviewed for themes of referral mechanisms, using thematic analysis and Joanna Briggs Institute appraisal instruments.
Results: Referral automation happens in a mere 18% of organizations, with low awareness (74.8% unfamiliarity) and stigma as points of hindrance. Active models like MUHC's pager system and coordinated pathways bring rise to uptake, while innovations like the Talk to Me program achieve 100% uptake. Virtual programs externally (e.g., YANA) are 80% possible in under-resourced settings.
Conclusion: Proactive, just culture-based referral systems are crucial to enabling second victim nurses, preventing distress, and enhancing patient safety.
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References
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa
Brunelli, M. V., Estrada, S., Celano, C., Bandriwskyj, C., Riquelme, R. J., Ortega, A., ... & Mesurado, B. (2023). Second victim experience and support from health professionals. Medicina, 83(6), 918-926. PMID: 38117711
Burlison, J. D., Scott, S. D., Browne, E. K., Thompson, S. G., & Hoffman, J. M. (2017). The second victim experience and support tool: validation of an organizational resource for assessing second victim effects and the quality of support resources. Journal of patient safety, 13(2), 93-102. DOI: 10.1097/PTS.0000000000000129
Cabilan, C. J., & Kynoch, K. (2017). Experiences of and support for nurses as second victims of adverse nursing errors: a qualitative systematic review. JBI Evidence Synthesis, 15(9), 2333-2364. DOI: 10.11124/JBISRIR-2016-003254
Chan, S. T., Khong, B. P. C., Pei Lin Tan, L., He, H. G., & Wang, W. (2018). Experiences of Singapore nurses as second victims: A qualitative study. Nursing & health sciences, 20(2), 165-172. https://doi.org/10.1111/nhs.12397
Chen, G. R., Sun, H. M., Huang, R. R., Ding, X. M., Li, J. L., & Pan, M. H. (2019). Qualitative studies on experiences and support needs of Chinese nurses as second victim: a meta-synthesis. J. Nurs. Sci, 34, 64-67.
Choi, E. Y., Pyo, J., Ock, M., & Lee, H. (2024). Development and evaluation of an external second victim support program for nurses: a single-group feasibility study. BMC nursing, 23(1), 694. https://doi.org/10.1186/s12912-024-02285-1
Cohen, R., Sela, Y., Halevi Hochwald, I., & Nissanholz-Gannot, R. (2023, July). Nurses’ silence: Understanding the impacts of second victim phenomenon among Israeli nurses. In Healthcare (Vol. 11, No. 13, p. 1961). MDPI. https://doi.org/10.3390/healthcare11131961
Dukhanin, V., Edrees, H. H., Connors, C. A., Kang, E., Norvell, M., & Wu, A. W. (2018). Case: a second victim support program in pediatrics: successes and challenges to implementation. Journal of Pediatric Nursing, 41, 54-59. https://doi.org/10.1016/j.pedn.2018.01.011
Edmonson, C., Bolick, B., & Lee, J. (2017). A moral imperative for nurse leaders: Addressing incivility and bullying in health care. Nurse Leader, 15(1), 40-44. https://doi.org/10.1016/j.mnl.2016.07.012
El Hechi, M. W., Bohnen, J. D., Westfal, M., Han, K., Cauley, C., Wright, C., ... & Kaafarani, H. M. (2020). Design and impact of a novel surgery-specific second victim peer support program. Journal of the American College of Surgeons, 230(6), 926-933. https://doi.org/10.1016/j.jamcollsurg.2019.10.015
Finney, R. E., Torbenson, V. E., Riggan, K. A., Weaver, A. L., Long, M. E., Allyse, M. A., & Rivera‐Chiauzzi, E. Y. (2021). Second victim experiences of nurses in obstetrics and gynaecology: A second victim experience and support tool survey. Journal of Nursing Management, 29(4), 642-652. https://doi.org/10.1111/jonm.13198
Gibalska-Dembek, A., & Sys, D. N. (2024). Medical personnel as the'second victim'of an adverse medical event-narrative review. General Medicine & Health Sciences/Medycyna Ogólna i Nauki o Zdrowiu, 30(2). doi: 10.26444/monz/189260
Hsu, M. C., Chou, M. H., & Ouyang, W. C. (2022). Dilemmas and repercussions of workplace violence against emergency nurses: A qualitative study. International journal of environmental research and public health, 19(5), 2661. https://doi.org/10.3390/ijerph19052661
James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of patient safety, 9(3), 122-128. DOI: 10.1097/PTS.0b013e3182948a69
Joint Commission on Accreditation of Healthcare Organizations. (2009). Joint Commission journal on quality and patient safety (Vol. 35, No. 7-12). Joint Commission Resources.
Kappes, M., Romero‐García, M., & Delgado‐Hito, P. (2021). Coping strategies in health care providers as second victims: A systematic review. International nursing review, 68(4), 471-481. https://doi.org/10.1111/inr.12694
Kappes, M., Delgado‐Hito, P., Contreras, V. R., & Romero‐García, M. (2023). Prevalence of the second victim phenomenon among intensive care unit nurses and the support provided by their organizations. Nursing in Critical Care, 28(6), 1022-1030. https://doi.org/10.1111/nicc.12967
Kang, J., Kwon, S. S., & Lee, Y. (2024). Clinical nurses’ work-life balance prediction due to patient safety incidents using classification and regression tree analysis: a secondary data analysis. BMC nursing, 23(1), 70. https://doi.org/10.1186/s12912-024-01719-0
Li, J., Yan, X., Chen, G., & Sun, H. (2023). Mindfulness meditation intervention improves the mindfulness awareness level of nurses’ second victims to enhance their psychological support. SAGE Open Nursing, 9, 23779608231178136. https://doi.org/10.1177/23779608231178136
Lim, S. H., Zainal, H., Lee, L. J., Binte Sunari, R. N., Choh, A. C. L., Teo, K. Y., ... & Aloweni, F. (2025). Second victim experiences and impact among acute care nurses: An exploratory study. International Nursing Review, 72(1), e12999. https://doi.org/10.1111/inr.12999
Logrono, K. J., Insao, C. M., Zubi, B., Macaaly, R., Al-Balawi, R. M., Swallmeh, E., & Al-Shukaili, K. (2025). 17 ‘Talk to me’second victim support program: cultivating empathy, empowerment, and equity for nurses and with the nurses. https://doi.org/10.1136/bmjoq-2025-IHI.17
Munn, Z., Barker, T. H., Moola, S., Tufanaru, C., Stern, C., McArthur, A., ... & Aromataris, E. (2020). Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. JBI evidence synthesis, 18(10), 2127-2133. DOI: 10.11124/JBISRIR-D-19-00099
Potura, E., Roesner, H., Trifunovic-Koenig, M., Tsikala, P., Klemm, V., & Strametz, R. (2024, October). Second victims among Austrian nurses (seViD-A2 study). In Healthcare (Vol. 12, No. 20, p. 2061). MDPI. https://doi.org/10.3390/healthcare12202061
Restrepo, E. M. (2016). Leaders against all odds: Women victims of conflict in Colombia. Palgrave Communications, 2(1), 1-11. https://doi.org/10.1057/palcomms.2016.14
Rinaldi, C., Leigheb, F., Vanhaecht, K., Donnarumma, C., & Panella, M. (2016). Becoming a “second victim” in health care: Pathway of recovery after adverse event. Revista de calidad asistencial, 31, 11-19. https://doi.org/10.1016/j.cali.2016.05.001
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. BMJ Quality & Safety, 18(5), 325-330. https://doi.org/10.1136/qshc.2009.032870
Scott, S. D., & McCoig, M. M. (2016). Care at the point of impact: insights into the second‐victim experience. Journal of Healthcare Risk Management, 35(4), 6-13. https://doi.org/10.1002/jhrm.21218
Stone, M. (2020). Second victim support programs for healthcare organizations. Nursing management, 51(6), 38-45. https://doi.org/10.1097/01.NUMA.0000662664.90688.1d
Ullström, S., Sachs, M. A., Hansson, J., Øvretveit, J., & Brommels, M. (2014). Suffering in silence: a qualitative study of second victims of adverse events. BMJ quality & safety, 23(4), 325-331. https://doi.org/10.1136/bmjqs-2013-002035
Vogt, A. J., Bartels, L., Grotzer, M., Bodenmann, G., Leibundgut, K., Rössler, J., & Landolt, M. A. (2024). Posttraumatic stress symptoms in parents of children with newly diagnosed cancer: 1-year trajectories and relationship variables as predictors. Journal of Pediatric Psychology, 49(11), 818-826. https://doi.org/10.1093/jpepsy/jsae077
Wade, L., Fitzpatrick, E., Williams, N., Parker, R., & Hurley, K. F. (2022). Organizational interventions to support second victims in acute care settings: a scoping study. Journal of patient safety, 18(1), e61-e72. DOI: 10.1097/PTS.0000000000000704
White, A. A., Brock, D. M., McCotter, P. I., Hofeldt, R., Edrees, H. H., Wu, A. W., ... & Gallagher, T. H. (2015). Risk managers' descriptions of programs to support second victims after adverse events. Journal of Healthcare Risk Management, 34(4), 30-40. https://doi.org/10.1002/jhrm.21169
Whittemore, R., & Knafl, K. (2005). The integrative review: updated methodology. Journal of advanced nursing, 52(5), 546-553. https://doi.org/10.1111/j.1365-2648.2005.03621.x
World Health Organization. (2020). Patient safety incident reporting and learning systems. World Health Organization.
Wu, A. W. (2000). Medical error: the second victim: the doctor who makes the mistake needs help too. Bmj, 320(7237), 726-727. https://doi.org/10.1136/bmj.320.7237.726
Yang, R., Gao, Y., & Ji, Z. (2023). The relationship between self-regulated learning, mindful agency, and psychological resilience in Chinese master of nursing specialists: A cross-sectional study. Frontiers in Psychology, 14, 1066806. https://doi.org/10.3389/fpsyg.2023.1066806
Authors
Copyright (c) 2025 Sanaa Nasser Abuallah, Rana Shoai Ali Hady, Reem Shoue Ali Hadi, Aisha Ali Yahia Dahish, Nazekh Mohammed Ibrahim Aqeel, Weaam Ali Abkar Khalil , Badriah Saleh Colaib Jawhar, Halima Muhammad Ali Hakami, Sarah Mohammed Ali Hakami, Ishraq Yahya Mohammed Asiri
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