What Did I Miss? Helping Second Victims Make Sense of Adverse Events  

Many anaesthesiologists will encounter an adverse event or near miss that stays with them. Albert Wu introduced the term “second victim” for clinicians harmed by such events.¹ The term draws attention to clinicians’ suffering, without equating this with patient harm. In Scott and colleagues’ study, clinicians described self-doubt, loss of confidence, and disruption to their professional and personal lives. From these accounts, the authors identified a recovery process ending in dropping out, surviving, or thriving.²

Second-victim literature often focuses on the acute stress response. Clinicians may experience shock, fear, guilt, intrusive recollections, disturbed sleep, impaired concentration, heightened arousal, loss of confidence, and difficulty functioning.² Peer-support models respond to this disruption through listening, normalisation and education about common reactions, support for coping, follow-up, and referral when further help is needed.^3–5 A recent systematic review reported short-term reductions in distress and isolation following peer-support interventions, but rated the evidence as low certainty; longer-term effects remain uncertain.⁵

Clinicians may, however, carry questions alongside the acute stress response, often replaying what happened and asking what they missed or could have done differently.² In Pelikan and colleagues’ survey, anaesthesia professionals most wanted a respected peer with whom to discuss the details of the event.⁶ Yet that programme directed peer-support conversations towards the event’s emotional implications, not the clinical details of what had happened.⁶

Local rationality, a principle used in human factors and system safety, provides language for describing the situation as it appeared to the clinician at the time.⁷ It asks why an action seemed sensible, given the clinician’s goals, available information, pressures, trade-offs, and resources. Afterwards, previously hidden conditions may become apparent, and the outcome is known. Both can change how the earlier action appears. A reconstruction based on local rationality therefore begins with what was visible at the time, rather than letting later knowledge determine its direction.

Local rationality also directs attention beyond one decision. An action is shaped by what others communicated, what had already happened, what demanded attention, and which options appeared available. Each participant acted from a different position, with access to different parts of the situation. Their perspectives can coexist, and each may reveal something relevant about how the event developed. A fuller reconstruction should not reduce these perspectives to a single, simplified version.⁷

Reconstructing how the situation developed and why the action made sense at the time is only part of what clinicians may need to understand. They may also have questions about the harm to the patient and the role their own actions played.^2,8 The experience may affect their confidence, assumptions, and sense of who they are.^2,9 Repeated attempts to make sense of a stressful event without reaching an understanding have been described as rumination associated with increased distress.⁹ For clinicians, developing a coherent account may therefore involve acknowledging the harm to the patient and their own involvement, explaining why their actions made sense within the situation, and placing the event within a broader understanding of themselves and their work.

Some descriptions of peer-support programmes do refer to reflection, reframing, or sense-making, without identifying a coherent account as an explicit aim or describing a structured method for reconstructing the event with the clinician.^3,4,6 Evaluations of peer-support programmes have assessed psychological distress, perceived institutional and collegial support, programme use, and perceived usefulness. These evaluations have not assessed whether clinicians came to understand the event more clearly.^4–6

Formal investigation may not answer the clinician’s questions about how the event developed and why their actions made sense at the time. In Ullström and colleagues’ study, 21 clinicians described how inadequate or delayed feedback made processing the event and reaching closure more difficult.⁸ Even timely feedback may present a linear explanation shaped by hindsight that locates the problem in the clinician’s actions without reconstructing why those actions made sense at the time.⁷

Peer support and formal investigation serve different purposes, but neither necessarily helps clinicians reconstruct why their actions made sense at the time. Local rationality supplies language for that reconstruction. By relating the clinician’s actions to the conditions under which they made sense, such a reconstruction can also provide a more precise basis for accountability. It may challenge explanations, including the clinician’s own, that reduce the event to individual failure.⁷

For anaesthesiology, two practical questions follow: “How do we support clinicians during the acute stress response?” and “How do we help them understand what happened?” Local rationality offers organisations and clinicians a shared language for the second: “Why did these actions make sense at the time?” Making this language part of how we think and talk about adverse events could support both organisational learning and clinicians’ efforts to develop a coherent account that includes the harm, their own actions, and the event’s implications for their professional and personal lives.

Author: Rebekka A. Hannivoort
Anaesthesiologist-Intensivist, Department of Anesthesiology, Amsterdam UMC, the Netherlands
MSc student, Human Factors and System Safety, Faculty of Engineering (LTH), Lund University, Sweden

References

1. Wu, A. W. (2000). Medical error: The second victim. BMJ, 320(7237), 726–727. https://doi.org/10.1136/bmj.320.7237.726
2. 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. https://doi.org/10.1136/qshc.2009.032870
3. Shapiro, J., & Galowitz, P. (2016). Peer support for clinicians: A programmatic approach. Academic Medicine, 91(9), 1200–1204. https://doi.org/10.1097/ACM.0000000000001297
4. Bursch, B., Ziv, K., Marchese, S., Aralis, H., Bufford, T., & Lester, P. (2024). Department of anesthesiology skilled peer support program outcomes: Second victim perceptions. The Joint Commission Journal on Quality and Patient Safety, 50(6), 442–448. https://doi.org/10.1016/j.jcjq.2024.03.006
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6. Pelikan, M., Finney, R. E., & Jacob, A. (2023). Use of the Second Victim Experience and Support Tool (SVEST) to assess the impact of a departmental peer support program on anesthesia professionals’ second victim experiences (SVEs) and perceptions of support two years after implementation. AANA Journal, 91(5), 371–379.
7. Woods, D. D., Dekker, S., Cook, R., Johannesen, L., & Sarter, N. (2010). Behind human error (2nd ed.). Ashgate.
8. Ullström, S., Andreen Sachs, M., 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
9. Park, C. L. (2010). Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychological Bulletin, 136(2), 257–301. https://doi.org/10.1037/a0018301