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System planning for modern-day Just Culture to mitigate worker distress and second victim response
  1. Joanna R Sells1,2,
  2. Irene Cole1,3,
  3. Charlie Dharmasukrit1,4,
  4. Amy Brown5,6,
  5. Christine Rovinski-Wagner7,8,
  6. Tamara L Tasseff6
  1. 1 VA Quality Scholars Program, San Francisco VA Health Care System, San Francisco, California, USA
  2. 2 Rocky Mountain MIRECC, Aurora, Colorado, USA
  3. 3 School of Nursing, University of California San Francisco, San Francisco, California, USA
  4. 4 Center for Nursing Excellence and Innovation, UCSF Health, San Francisco, California, USA
  5. 5 VA Readjustment Counseling Service, District 3, St. Louis, Missouri, USA
  6. 6 VA Quality Scholars Program, Iowa City VA Medical Center, Iowa City, Iowa, USA
  7. 7 Office of Integrated Veteran Care, VA Health Connect, Veterans Health Administration, Washington, DC, USA
  8. 8 VA Quality Scholars Program, White River Junction VA Medical Center, White River Junction, Vermont, USA
  1. Correspondence to Dr Joanna R Sells, VA Quality Scholars Program, San Francisco VA Health Care System, San Francisco, CA 94121, USA; drjoannasells{at}

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Healthcare organisations throughout the USA have been experiencing regular yet unpredictable stressors from sources including extreme weather events, acts of mass violence and the COVID-19 pandemic. These events can create instant demand for critical equipment, the need for additional temporary urgent care units, mobilisation of clinicians and collaborations with external organisations for determining best practices in extraordinary circumstances. Stories of heroism and grit pour out during, and after, these challenges. Inevitably, vulnerabilities also become exposed, some of which affect our healthcare workers who may become second victims.1

James sought to identify and enumerate accidental adverse events and preventable deaths occurring to patients because of care, finding that up to 400 000 premature deaths may have occurred due to clinical errors between 2006 and 2012.2 Commission of an error or accident by a clinician most often leads to remorse exhibited by symptoms including troubling memories, anxiety, anger towards self, regret, fear of committing future errors, embarrassment and guilt.3–5 Second victim syndrome can occur no matter the years of professional experience and can be life altering.6

The current definition of second victim is evidence-based and centres on the commission of a clinical error. Coined by Wu,7 further defined by Scott and colleagues8 and expanded by expert consensus following completion of a systematic literature review to a second victim is ‘any health care worker, directly or indirectly involved in an unanticipated adverse patient event, unintentional healthcare error or patient-related injury, and becomes victimised in the sense that also the worker is negatively impacted’.7–9 We honour these definitions and agree that each of these definitions may fit in cases of accidental commission of events during the course of routine patient care.

System risks of medical errors exist during routine healthcare. Risks include, but are not limited to, hospital …

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  • Contributors All authors contributed to conceptualising, writing and editing this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Author note The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. This work was supported by the VA Quality Scholars Fellowship (VAQS) from the United States (U.S.) Department of Veterans Affairs.