Leadership and Organizational Responses After Patient Safety Incidents: A Systematic Review of Second-Victim Outcomes and Evidence Gaps in Safety Behaviors

Abstract

Background/Objectives: Patient safety incidents can adversely affect healthcare professionals, but relationships between leadership and organizational responses, clinician recovery, professional consequences, and safety-related outcomes remain incompletely synthesized. This review examined contemporary quantitative evidence on these relationships and the extent to which directly measured safety behaviors and patient-safety outcomes have been evaluated. Methods: This PROSPERO-registered systematic review (CRD420261453278) followed PRISMA 2020 and PRISMA-S. PubMed and Scopus were searched as the primary bibliographic databases, supplemented by Europe PMC and OpenAlex and by forward citation searching in Scopus and the Web of Science Core Collection, for English-language studies published from January 2021 through July 2026. Two reviewers independently screened records and extracted data; design-specific JBI appraisal judgments were agreed by two reviewers. Heterogeneity precluded meta-analysis, and findings were synthesized narratively using SWiM-informed structured reporting. Results: Of 6838 records, 44 studies were included. Distress/recovery was assessed in 40 studies (90.9%), professional consequences in 21 (47.7%), other safety-related outcomes or indicators in five (11.4%), and disclosure-related behavior in one (2.3%). No study prospectively evaluated incident or near-miss reporting or speaking up as a principal exposure-linked outcome. Supportive organizational responses, just and non-punitive cultures, learning-oriented safety climates, and structured support were generally associated with less distress, more favorable recovery, and fewer negative professional outcomes. Structured-support evaluations suggested feasibility, acceptability, and favorable short-term signals but did not establish intervention effectiveness. Conclusions: Contemporary evidence is substantially stronger for clinician recovery and professional functioning than for safety behavior or patient outcomes. Predominantly cross-sectional, self-reported, and uncontrolled evidence precludes causal conclusions. Direct evaluation of reporting, disclosure, speaking up, verified workforce outcomes, and patient-safety effects remains a major research priority.