LIVING THROUGH PATIENT SAFETY INCIDENTS: A QUALITATIVE STUDY OF SECOND VICTIM EXPERIENCES AMONG INDONESIAN HEALTHCARE WORKERS

Author : Inge Dhamanti

Abstract : Background: Adverse events (AEs) affect multiple stakeholders, including patients and families as first victims, healthcare professionals as second victims, and healthcare organisations as third victims. Second victim syndrome (SVS) has significant psychological, professional, and organisational consequences; however, evidence from Indonesia remains limited. Purpose: To explore healthcare workers' experiences of second victim syndrome and identify existing support mechanisms and organisational needs within the Indonesian healthcare context.Methods: A qualitative descriptive study was conducted using five focus group discussions involving healthcare professionals, healthcare managers, and policymakers with experience in patient safety incident reporting or investigation. Data were analysed using thematic analysis. Results: A total of 45 participants participated in the study. Four overarching themes emerged. First, second victim syndrome remained insufficiently recognised within healthcare organisations, contributing to under-recognition and underreporting. Second, psychological distress - including guilt, fear, self-doubt, and emotional burden - was more frequently discussed than physical symptoms, although some participants described positive adaptation and increased resilience following incidents. Third, support for second victims primarily occurred through colleagues, supervisors, and organisational initiatives; however, access to structured psychological support remained limited, and blame-oriented cultures continued to hinder recovery. Finally, participants emphasised that effective second victim support should be institutionalised within patient safety systems rather than relying solely on individual coping strategies. Conclusions: Second victim syndrome is recognised by healthcare workers in Indonesia but remains inadequately addressed at the organisational level. Establishing structured second victim support programmes, strengthening supportive leadership and peer support, and embedding just culture principles within patient safety systems are essential to improve workforce wellbeing, organisational resilience, and patient safety.

Keywords : Adverse event, second victims syndrome, second victim support, patient safety incident.

Conference Name : International Symposium on Healthcare Quality and Patient Safety (ISHQPS-26)

Conference Place : Bangkok, Thailand

Conference Date : 23rd Jul 2026