Better Patient Safety Prevents ‘Second Victims’ of Medical Errors – Healthcare Workers

Updated: Sep 12

By Paul Gallese, PT, MBA

Medical errors can have devastating effects on people known as “second victims” – caregivers who make mistakes or who witness harm to patients. One tragic example of a second victim is Kimberley Hiatt, a 50-year-old nurse who committed suicide seven months after making a mathematical error leading to an overdose and the death of a critically ill infant (Grissinger, 2014).

With medical errors estimated as the third leading cause of death in America (Malkary & Daniel, 2016), it’s no stretch to assume that many if not most medical professionals have made a mistake causing some degree of harm. Still, between the accident and her suicide, hospital leaders terminated Kimberley’s employment, according to media reports. She agreed to pay a fine and accepted four-year probation to meet state licensing disciplinary actions. Just before her death, she passed an advanced cardiac life support certification exam to qualify for a flight nurse position. But she received no job offers, increasing her isolation, despair and depression. Many patients and families who received care from her attended her memorial service (Grissinger, 2014).

In a Baltimore Sun article, Dr. Albert Wu, an internist and researcher in medical safety at the Johns Hopkins Bloomberg School of Public Health, said studies suggest that between 10 percent and 50 percent of healthcare workers identify that they have been a second victim of an adverse event (Pitts, 2015). These second victims can experience psychological and emotional harm including guilt, retribution from co-workers, fear and post-traumatic stress disorder (PTSD).

Caregivers must be assisted and encouraged to report errors, not blamed

Rather than assigning blame to caregivers for adverse events, healthcare organizations must encourage caregivers to report these events and use the reports to fix system flaws, the cause of most medical errors (The Joint Commission, 2019).

While working to reduce medical errors, hospitals leaders are also beginning to launch initiatives designed to help caregivers who are coping with the aftermath of an error or with other stressors. Caring for the Caregiver, an initiative designed by the Maryland Patient Safety Center and Johns Hopkins Hospital's Armstrong Institute for Patient Safety and Quality, guides hospitals on how to set up peer-responder programs that deliver psychological first aid and emotional support. Banner Estrella Medical Center developed a meditative approach that is used both for patient pain management and caregiver stress management (Gallese, July 30, 2019). The Armstrong Institute’s blog provides a helpful “dos and don’ts” article on how to support a second victim.

These kinds of interventions can help hospitals to maintain an alert and stable workforce. According to the Nursing Solutions Inc. National Health Care Retention and RN Staffing Report, the average cost to replace a bedside registered nurse is estimated at more than $50,000, and the turnover rate for bedside RNs is 17.2 percent per year. The average hospital loses $4.4 million to $6.9 million each year due to turnover (NSI, 2019).

A happy and engaged workforce produces clinical, financial and other benefits

By minding and addressing the needs of stressed caregivers, hospitals can move the needle in a positive direction on many measures – clinical, financial and more. A correlation between stress, burnout and medical errors has been established (Dyrbye et al, 2017). Errors and a failure to comply with patient safety protocols contribute to healthcare-acquired infections and conditions, suboptimal patient outcomes, dissatisfied patients, staff turnover, and the need to place dollars that could go toward improvements in patient care into professional liability insurance reserves instead (Gallese, July 16, 2019). Improvements on measures of how well staff comply with precautions such as hand hygiene and timely patient rounding can improve patient safety and lead to less adverse events and higher scores on patient and staff satisfaction (Vitalacy, March 14, 2019).

Joining in an industry-wide effort to decrease healthcare-acquired infections and conditions, including medical errors, Vitalacy has developed a patient safety platform that enables hospitals to monitor hand hygiene compliance and nurse rounding activities and make them more effective. The platform has proved to reduce hospital-acquired infections through better hand hygiene (Nour-Omid, 2019) and helps nurses track shift duration, shift frequency and miles walked during rounding. A fatigue scoring algorithm notifies unit clerks and nurse managers when a caregiver experiences burnout symptoms.

Most caregivers do their jobs out of dedication to their patients and feel privileged to serve them. It is only right and fair to do whatever is possible to help them in times of need. There is no reason for a caregiver to descend into psychological despair or physical illness, or even to resort to suicide, because he or she made a mistake. All humans make mistakes. It’s our job to help those victimized by the mistakes, not to cast judgment, and to do whatever we can to make any mistake less likely to happen again.


Dyrbye, LN, et al. Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care. National Academy of Medicine, 2017.

Gallese, P. An interview with Linda Bennett, Ph.D. How to use guided imagery to help caregivers manage stress, burnout and fatigue. Vitalacy blog, July 30, 2019.

Gallese, P. How better patient safety can turn your hospital’s professional liability insurance reserve into margin. Vitalacy blog, July 16, 2019.

Grissinger, M. Too many abandon the “second victims” of medical errors. Pharmacy and Therapeutics, Sept. 2014;39(9):591-592.

Maraky, MA & Daniel, D. Medical error – the third leading cause of death in the U.S. BMJ, 2016;353:i2139.

Nursing Solutions Inc. (NSI). 2019 National Heath Care Retention and RN Staffing Report. 2019.

Pitts, J. Program helps caregivers under stress for errors. Baltimore Sun, June 21, 2015.

The Joint Commission. Sentinel event alert: developing a reporting culture. June 4, 2019.

Vitalacy, Inc. Finding new ways to prevent healthcare-acquired infections and conditions. Mar. 14, 2019.

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