ABSTRACT
If there is one thing that sets a second victim apart from the first, it is the feeling of guilt. The second victim, after all, is often the one who feels responsible for letting or making the event happen. He or she is also the one whose very job it was not to have the event happen-to prevent it. The second victim created the first. This can cause havoc and involve overwhelming and unfamiliar emotions and feelings. But how guilty “should” a second victim feel? In most cases, it is easy to point to all kinds of circumstances and factors that contributed to the bad outcome. After all, the second victim seldom acted in a vacuum. If it had not been that particular nurse, or pilot, or doctor, or commander, the same sort of thing could still have happened. The conditions for it were all in place. Just think about nurse Julie, whose work setting contained all the error traps that might just as well have caught another nurse: the double shift and manpower shortages, fatigue, the ergonomic booby trap of interchangeable IV ports, the approved policy of prepping the medication before an anesthesiologist showed up, and more.
