Second victim: the doctor after a mistake

The shift ended hours ago, but the resident is still going over the same scene on the bus. The abdominal pain that seemed benign, the discharge at three in the morning, the colleague's call late in the afternoon warning that the patient had come back in a serious condition. She sleeps badly, rereads the chart on her phone, avoids walking past the ward corridor and asks herself, for the first time, whether she chose the right profession. No one on the team touched on the subject. The silence feels like a form of respect, but it weighs like a judgment.

This experience has a name. Second victim is the health professional who suffers after an adverse event involving the patient, who remains the first victim. This guide explains where the term comes from, what studies show about the emotional impact and recovery, why distress after an error also affects the safety of the next patients, what is known about support programs and what you can do, as a student, resident or preceptor, to get through this moment without hiding what happened.

Key points

• The term second victim was proposed in 2000, in an editorial that recalled that the doctor who makes a mistake also needs help (Wu, 2000).
• In a meta-analysis, intrusive memories, anxiety, anger at oneself and remorse appeared in most of the professionals studied (Busch et al., 2020).
• Recovery usually follows six predictable phases, from the initial confusion to the moment of moving on (Scott et al., 2009).
• Perceived error and distress feed each other in a cycle: one raises the chance of the other in the following months (West et al., 2006).
• Peer support is the most studied intervention, with short-term relief and still limited evidence for the long term (Ong et al., 2025).
• Students and residents also become second victims, and almost always prefer to talk to a trusted colleague.

Summary

• What the second victim is
• What happens to the doctor after an error
• The six phases of recovery
• Why this is also a patient safety matter
• Students and residents are second victims too
• What is known about peer support
• What to do in the first hours and weeks
• The error as information in NEXO
• Frequently asked questions
• Checklist for after an adverse event

What the second victim is

In 2000, Albert Wu published a short text in the BMJ with a direct title: the doctor who makes a mistake also needs help (Wu, 2000). The idea was not to take the patient out of the center. The patient who suffers the harm is and remains the first victim, and their family comes right beside them. Wu's point was another one: medical culture treated error as a character flaw, and the professional involved was left alone with the blame, with no room to talk, no guidance and often without knowing whether their own service was on their side.

Over time, the concept broadened. Today second victim refers to any health professional who is emotionally hurt after an adverse event, an error or even an unexpected outcome in which there was no error at all. A systematic review found prevalence estimates between 10.4% and 43.3% of professionals after an adverse event, with emotional, cognitive and behavioral reactions (Seys et al., 2013). The wide range reflects different methods, but the message is the same: this is not something rare, it is a common experience of clinical life.

Adverse event, error and bad outcome are not the same thing

It is worth separating situations that often get mixed up in the mind of someone who is suffering. An adverse event is harm to the patient caused by care, with or without error. An error is an action or omission that departed from what should have been done, with or without harm. A bad outcome is when the disease follows its own course despite adequate care. A near miss is a failure intercepted before it reaches the patient. And a diagnostic error is a delayed, wrong or missed diagnosis, a specific form of error.

The second victim can arise in any of them. Someone who loses a young patient after doing everything right can suffer as much as someone who got the dose wrong. This separation is not meant to measure who deserves to suffer, but to guide the analysis afterward: what was system, what was decision, what was chance. The post about hindsight bias and outcome bias shows how the known outcome distorts the judgment of those looking back, including the judgment we make of ourselves.

Why the term bothers some people

There are criticisms of the term. Patient representatives point out that calling the professional a victim can sound like an evasion of responsibility. The criticism is fair and helps to use the word with care. Acknowledging the doctor's suffering does not reduce the duty to tell the patient the truth, to repair the harm when possible and to change what led to the error. In practice, the most serious programs address both things together: transparency with the patient and care for the team. The guide on how to communicate a diagnostic error to the patient covers the first side; this text covers the second.

What happens to the doctor after the error

One of the largest surveys on the subject heard 3,171 doctors in the United States and Canada. After errors, 61% reported more anxiety about future errors, 44% loss of confidence, 42% difficulty sleeping and 42% lower job satisfaction, and only 10% agreed that institutions supported them adequately to deal with stress (Waterman et al., 2007). The same study showed that the suffering was greater when the doctor was dissatisfied with the way the error was disclosed to the patient and when the doctor feared a lawsuit.

A later meta-analysis gathered the most frequent symptoms. Intrusive memories appeared in 81% of professionals, anxiety in 76%, anger at themselves in 75%, regret in 72% and distress in 70% (Busch et al., 2020). Fear of new errors, shame, guilt and difficulty sleeping were also common in the same analysis. The confidence intervals are wide, because the studies are heterogeneous, but the picture is consistent.

Reactions that usually appear

The accounts group into a few types of reaction. Knowing this list helps you realize that what you feel has a precedent and is not a sign of weakness:

• Emotional: guilt, shame, anger, sadness, fear of being found out, feeling like a fraud.
• Cognitive: mentally replaying the scene, doubting your own competence, difficulty concentrating.
• Physical: insomnia, fatigue, tension, loss of appetite.
• Behavioral: avoiding the place or the type of patient, ordering too many tests, isolating yourself from the team.
• Professional: thinking about changing specialty, reducing the clinical workload or leaving the career.
• Constructive: reviewing the protocol, studying the topic, taking part in the analysis of the event.

The last category matters. The review by Seys and colleagues described defensive changes, such as ordering unnecessary tests, and constructive changes, such as becoming more attentive to steps that used to be automatic (Seys et al., 2013). The same event can push you one way or the other, and the type of support received seems to weigh on that direction.

How much the fear of a lawsuit weighs

Fear of a lawsuit appears in almost every account and makes the suffering worse (Waterman et al., 2007). It also pushes toward silence: those who fear punishment report less, and those who report less receive less support. That is why the discussion about the second victim goes together with the discussion about a just culture, which we will see further on. For the student, the fear is usually different: the grade, the preceptor's evaluation, the reputation in the class. The logic is the same.

The six phases of recovery

An American team interviewed 31 professionals who had lived through adverse events and noticed that the stories followed a similar trajectory. The group described six phases and stated that the path after the event is, to a large extent, predictable (Scott et al., 2009). This predictability is useful: if the course is known, support can arrive at the right time.

Phase	What the person experiences	Typical question	What helps
1. Chaos and response to the accident	Caring for the patient while trying to understand what happened	How did this happen?	Someone on the team takes over part of the work
2. Intrusive reflections	Replaying the scene, thinking about the "what ifs"	What should I have done?	Listening without judgment in the first days
3. Restoring integrity	Seeking someone trusted and gauging colleagues' reactions	What will others think of me?	A respected colleague who says this happens
4. Facing the investigation	Event analysis, interviews, possible lawsuit	What will happen to me?	Clear information about the process and the next step
5. Emotional first aid	Seeking support, not always finding it	Where do I look for help?	Peer support and easy access to specialized help
6. Moving forward	Giving up, surviving or growing	How does this change me?	Turning the event into improvement and teaching

The last phase has three possible paths. Some professionals give up, changing fields or leaving the profession. Others survive: they keep working, but carry the event like an open wound. A third group grows, and several interviewees said that taking part in improvement or patient safety projects helped them enjoy the work again (Scott et al., 2009).

The phases are not a staircase

The phases overlap and can come back. A hearing scheduled months later reopens phase four. A similar patient on shift reopens phase two. Knowing this avoids a common trap: thinking that if it still hurts after weeks, something is wrong with you. What helps is noticing where you are and asking for the kind of support that fits that moment.

Why this is also a patient safety matter

It would be possible to treat the second victim only as a professional wellbeing topic. The data suggest it is also a safety topic. In a longitudinal study with internal medicine residents, perceived errors were associated with more distress in the following months, and burnout and lower empathy were associated with a higher chance of new perceived errors (West et al., 2006). The authors described a reciprocal cycle: the error causes distress, and distress raises the risk of erring again.

A survey with American surgeons found a similar relationship. Burnout and depression were independent predictors of reporting a recent serious error, and each additional point on the emotional exhaustion scale was associated with a 5% increase in the chance of reporting an error (Shanafelt et al., 2010). These studies use self-reported errors and do not prove cause, but they reinforce a practical conclusion: ignoring the professional's distress does not protect the next patient.

Clinical reasoning after a scare

The subtler effect shows up in reasoning. Someone who has just made an error tends to overestimate the chance of the diagnosis they missed and starts asking for it in everyone. It is a form of availability bias: what is vivid in memory seems more likely than it is. Emotion also enters decisions in other ways, as the text on affective bias in diagnosis shows. Noticing this effect does not remove the fear, but it helps separate the true lesson from excessive zeal.

Students and residents are also second victims

Some think the topic only concerns fully trained physicians, who sign off on the conduct. The data show the opposite. In an Italian cross-sectional study with health students and residents, the prevalence of those who had experienced a safety incident was 25.58%, lower among medical students (14.37%) and higher among residents (43.53%) (Rinaldi et al., 2022). The most common transient symptom was the feeling of working badly, and the most common lasting symptom was hypervigilance. No resident involved talked with the patient or the family.

In a study with obstetrics and gynecology residents and preceptors in the United States, both those in training and those supervising reported a second victim experience, and both groups named talking with colleagues as their preferred support (Torbenson et al., 2021). The authors suggested that residency programs offer peer support right after unexpected events, because this kind of experience appears early in the career.

What is different for those in training

Students and residents live the second victim experience with a few extra layers:

• Hierarchy: it is hard to talk about the error with someone who also evaluates you.
• Identity under construction: a serious event can shake the idea that you are cut out for medicine, a topic that connects with impostor syndrome.
• Little autonomy: often the decision was collective, but the blame stays with whoever was on the front line.
• Lack of a support routine: few medical schools have a clear pathway for students after an incident.
• Accumulated fatigue: the event hits a body that is already exhausted, as the post on burnout in medical school shows.

None of this means you should be spared from the analysis. It means the analysis needs to come together with support, and that the supervising physician has a big role in showing that talking about the error is part of the work, not a confession.

What is known about peer support

The most studied intervention is peer support: trained colleagues who reach out to the professional soon after the event, listen, normalize reactions and point to paths forward. A recent systematic review concluded that this type of support offers short-term relief, but with limited long-term impact and little standardization of outcome measures (Ong et al., 2025). The same review found more promising results in structured psychological interventions, such as cognitive behavioral therapy and mindfulness programs, which are still little studied.

Examples of programs

The RISE program at Johns Hopkins Hospital built a network of responders from various professions. Responders reported handling 88% of contacts well, and demand grew gradually over the years, although low awareness was a barrier (Edrees et al., 2016). In an anesthesiology department, implementing a trained peer program increased the perception that formal emotional support was available and that the organization learned from events (Bursch et al., 2024).

To measure the problem, there is a validated questionnaire, the SVEST, which assesses reactions and the quality of support. In the validation, the most desired support option was "a respected colleague to talk about the details of what happened" (Burlison et al., 2017). The result repeats what appears among residents: the first support people want is from someone who understands the work.

Just culture as the backdrop

Support programs work poorly in punitive environments. An integrative review concluded that the perception of organizational and peer support is part of just culture, and that non-punitive guidelines and feedback on reports are needed for support to be real (White and Delacroix, 2020). Just culture is not the absence of accountability. It is the distinction between human error, at-risk behavior and recklessness, with a different response for each. In an environment like this, reporting the error becomes the expected behavior, and morbidity and mortality sessions become a space for learning, not exposure.

What to do in the first hours and weeks

There is no single script, and each service has its own pathway. The steps below gather what appears most often in the studies and programs described above. The order matters: first the patient, then the institutional pathway, then you.

1. Take care of the patient and of immediate safety. Ask for help if you need it.
2. Let those who need to know know: the supervising physician, the physician in charge of the shift, the nursing team.
3. Record the facts in the medical record, objectively and at the right time.
4. Talk to someone you trust in the first days, preferably a colleague who understands the work.
5. Take part in the analysis of the event, thinking about the system and not only about yourself.
6. Seek the help you need if the distress persists, interferes with sleep or comes with thoughts of giving up on everything.

For those who are a colleague or a supervising physician

If you see a colleague go through this, the most useful gesture is usually simple. Ask how they are, without immediately asking for technical details. Tell them, if it is true, that you have been through something similar. Offer concrete help, such as covering a task. Avoid phrases that end the conversation, such as "it happens to everyone" said in a hurry, or the technical analysis done in the hallway. The technical conversation has its proper time, and it comes later. Those who lead the team have a special role, a topic the post on clinical leadership for interns and recent graduates develops.

Turning the event into learning

Over time, it is worth looking at the event as a source of learning. Write down what you knew at the time, separate from what you learned afterward. List the decisions and what influenced each one. Identify what was a knowledge gap, what was a reasoning failure and what was the system. This distinction is the subject of the post about knowledge gap or clinical reasoning gap. Many professionals say that this exercise, done with support, was what allowed them to move forward without forgetting.

Error as information in NEXO

NEXO treats error as information. In the case of the day, the diagnosis arrives in up to six clues, and the proximity in ICD-10 shows how far each guess was from the answer. Guessing close is useful data for the next hypothesis, and guessing far shows where the reasoning went off track. The cases are fictional with a real clinical presentation, so error there hurts no one.

This does not replace support from people after a real event with a patient. What a diagnosis game can offer is a safe place to practice the habit of looking at your own error with curiosity, without shame, and of separating the clue you misread from the clue that simply was not there. The guide on what NEXO is explains the whole match, and the NEXO blog gathers other texts on error and clinical reasoning.

If you coordinate a medical school, a student league or a residency and want cases for discussions about error and safety, see NEXO Closer. Researchers in medical education can propose studies through NEXO Researcher. Physicians who review cases take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.

Frequently asked questions

What is a second victim in medicine?

It is the health professional who suffers emotionally after an adverse event with a patient. The term was proposed by Albert Wu in 2000 (Wu, 2000). The patient remains the first victim.

What are the most common symptoms?

Intrusive memories, anxiety, anger at oneself, regret, fear of new mistakes, shame, guilt and insomnia were the most frequent in a meta-analysis (Busch et al., 2020).

How long does it last?

It varies a lot. Recovery usually goes through six phases, from initial confusion to moving forward, and the phases can overlap or return (Scott et al., 2009).

Does there have to be an error for someone to become a second victim?

No. An unexpected bad outcome, even with adequate care, can also cause this suffering (Seys et al., 2013).

What helps most?

The most desired option in the questionnaires is talking with a respected colleague (Burlison et al., 2017). Peer support brings short-term relief, and structured psychological interventions look promising (Ong et al., 2025).

Do students go through this too?

Yes. In an Italian study, students and residents reported involvement in safety incidents and symptoms typical of second victims, more frequent among residents (Rinaldi et al., 2022).

When should you seek specialized help?

When the suffering persists for weeks, interferes with sleep and work, or comes with thoughts of giving up on everything. In these cases, seek the help you need in the mental health services of your school, hospital or city.

Checklist for after an adverse event

• Patient first: immediate safety and honest communication.
• Service flow: inform, record and report.
• A conversation in the first days: with someone who understands the work.
• Facts separated from the outcome: what you knew at the time.
• System analysis: what can change for the next patient.
• Specialized help: if the suffering persists, seek the help you need.

Want to practice the habit of looking at error as information? Play the case of the day on NEXO.

References

1. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000. PubMed
2. Seys D, Wu AW, Van Gerven E, Vleugels A, Euwema M, Panella M, et al. Health care professionals as second victims after adverse events: a systematic review. Eval Health Prof. 2013. PubMed
3. Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007. PubMed
4. Busch IM, Moretti F, Purgato M, Barbui C, Wu AW, Rimondini M. Psychological and psychosomatic symptoms of second victims of adverse events: a systematic review and meta-analysis. J Patient Saf. 2020. PubMed
5. 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. PubMed
6. West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006. PubMed
7. Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010. PubMed
8. Rinaldi C, Ratti M, Russotto S, Seys D, Vanhaecht K, Panella M. Healthcare students and medical residents as second victims: a cross-sectional study. Int J Environ Res Public Health. 2022. PubMed
9. Torbenson VE, Riggan KA, Weaver AL, Long ME, Finney RE, Allyse MA, et al. Second victim experience among OBGYN trainees: what is their desired form of support? South Med J. 2021. PubMed
10. Ong TSK, Goh CN, Tan EKYE, Sivanathan KA, Tang ASP, Tan HK, et al. Second victim syndrome among healthcare professionals: a systematic review of interventions and outcomes. J Healthc Leadersh. 2025. PubMed
11. Edrees H, Connors C, Paine L, Norvell M, Taylor H, Wu AW. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. BMJ Open. 2016. PubMed
12. Bursch B, Ziv K, Marchese S, Aralis H, Bufford T, Lester P. Department of Anesthesiology skilled peer support program outcomes: second victim perceptions. Jt Comm J Qual Patient Saf. 2024. PubMed
13. Burlison JD, Scott SD, Browne EK, Thompson SG, Hoffman JM. The Second Victim Experience and Support Tool: validation of an organizational resource for assessing second victim effects and the quality of support resources. J Patient Saf. 2017. PubMed
14. White RM, Delacroix R. Second victim phenomenon: is "just culture" a reality? An integrative review. Appl Nurs Res. 2020. PubMed