"Second Victims" of Fatal Errors in Pharmacy

The “Support for ‘Second Victims’” editorial in the current issue of American Journal of Health-System Pharmacy captured my attention. I’m not familiar with the term “second victim,” but I am familiar with the problem it describes.

I have made mistakes in my pharmacy practice, but as far as I know, they were caught before anyone got hurt. However, I know a few pharmacists whose errors have been fatal. Those pharmacists were the “second victims,” often shunned by their colleagues or employers and left to deal with the aftermath of traumatizing events alone.

The editorial author was a “second victim” who was able to refocus her career on patient safety and become an advocate for both patients and health care professionals. In sharing her story, she reminded me, “There but for the grace of God go I.” I could just as easily have been involved in a fatal error, but fortunately, I wasn’t.

This serves as a good reminder to stay not only vigilant, but also humble. In being transparent about errors, pharmacists need to reach out to both victims: the patient and the health care professional.