Human errors are inevitable, and patient safety incidents are inescapable even when all efforts are applied to prevent them from happening. Therefore, when patients are harmed by mistakes, what matters most is not the gravity of the injury they sustained, but how their case is handled in the immediate aftermath. To facilitate the management of patient safety incidents, Timothy McDonald and colleagues, in their paper titled Responding to patient safety incidents: the “seven pillars”, have identified seven major principles or pillars of responding to patient incidents which are:
- Incident reporting: this triggers the process of responding
- Incident investigation: this includes a root-cause analysis (RCA) of the incident
- Communication with the patient and family throughout the process. This includes full disclosure if the care provided was found to be ‘unreasonable’
- Apology and rapid remediation ‘when an investigation reveals that the patient harm resulted from unreasonable care’.
- System improvement based on the findings of the investigation.
- Data tracking and performance evaluation: this reviews all aspects of the incident ‘for internal quality assurance, research, public outreach and dissemination’.
- Education and training to help in the ‘healing and learning processes’ of those involved in the incident. It also includes peer-peer support and fitness-to-work assessments.
Robert Truog and colleagues also addressed the first priorities of responding to patient safety incidents in their book Talking with Patients and Families About Medical Error. They focused on how victims and their families should be treated, and they emphasised the importance of rapidly implementing the following 7 critical measures:
- Attending to the on-going care of the patients medical needs
- Notifying those who need to be involved in a timely way
- Arranging a disclosure meeting and determining who would attend
- Sequestering any faulty equipment for future investigations
- Gathering information from all involved
- Deciding who would lead the discussion and who will take responsibility for following up
The above reflect the fact that at the heart of the response to patient safety incidents is addressing the immediate distress caused to patients and their families. This distress is deep and wide-ranging as highlighted by Tom Debanco and Sigal Bell in their paper titled Guilty, afraid, and alone-struggling with medical error. Debanco and Bell illustrated the tumultuous concerns and emotions of victims of patient safety incidents which include the anxiety of further harm, and the fear of retribution from health care workers if they express their worries. The authors also referred to the less-recognised emotions of family members following patient safety incidents, and these include the feelings of guilt for ‘not keeping close enough watch’ to prevent the events from transpiring. They also pointed out that affected families may become isolated if clinicians turn away from them and ‘close ranks‘ after patient safety incidents.
The UK National Patient Safety Agency (NPSA) has also published guidelines for junior doctors on how to respond to patient safety incidents in a document titled Medical Error. What to do if things go wrong. Amongst their recommendations are
- Tell your consultant or supervisor
- Review the patient’s clinical care
- Contact your medical defence organisation
- Complete an adverse incident reporting form
- Familiarise yourself with the complaints procedure
- Document details of the incident as soon as possible
- Apologise to the patient
The last item comes under the concept of ‘being open‘, and it also consists of acknowledging the incident and explaining how things went wrong. The NPSA also reassures doctors that ‘saying sorry is not an admission of liability and is the right thing to do’.
We will explore this theme in more detail in future posts starting next week with The benefits and challenges of patient safety incident disclosure.