Purpose: Well-intentioned, conscientious nurses make medication errors. The subsequent feelings of guilt, remorse, and loss of personal and professional self-esteem these nurses experience are well documented. In this paper, we analyze the concept of "second victim" within the context of medication administration errors. We also examine factors that contribute to nurses becoming second victims after making an error.

Practice implications: Implications for nurses and nursing practice include nurses being given a greater degree of authority in designing the nursing work environment. Implications for nurses and nursing practice are presented.

Conclusion: Further study is needed to more fully understand this phenomenon and to discover appropriate support mechanisms and interventions to minimize the harm to nurses.