02.04.03. Support following a patient safety incident
MRTs are fully supported following a patient safety incident
The toll of patient safety incidents
- A patient safety incident is an event or circumstance which could have resulted, or did result, in unnecessary harm to the patient1.
- A patient safety incident can have profound consequences for the MRT as well as the patient2.
- Common reactions reported by professionals involved in incidents include distress, self-doubt, confusion, fear, remorse, guilt, feelings of failure and depression, anger, shame and inadequacy that often persist for longer periods3
- Both poor patient outcomes and higher degrees of perceived personal responsibility seem to amplify emotional distress for carers3
- Litigation and complaints impose an additional burden2
- Following an incident, healthcare professionals have been shown to react by sometimes practicing more defensively or by distancing themselves from the sources of potential incidents (restricting scope of practice)3.
- Defensive practice can lead to a degradation in the quality of care and a system that is more prone to error3
Importance of support for MRTs
- A just and trusting culture, including management support for disclosure and incident reporting, helps provide reassurance that incidents are being handled in the appropriate way.
- Talking and listening to colleagues, including professional reaffirmation and reassurance, is important in dealing with and being able to learn from incidents2.
- Studies have shown that healthcare professionals benefit from the opportunity to discuss patient safety incidents with their peers in both formal and informal settings2
- Concerns about professional credibility and job security may be addressed in this way
- The process of disclosure has been shown to help the healthcare professional recover from the experiences of a patient safety incident1.
- Immediate practical support for MRTs could include education on disclosure of safety incidents, liability and/or associated legislation2.
- MRT’s should feel able to report adverse events and close calls without fear of inappropriate reprimand or punishment4.
- MRT’s should foster a culture of safety in which incidents are an opportunity for learning4.
- Consideration of accountability may include investigations and/or disciplinary proceedings within a hospital or regulatory authority4.
- In cases where the outcome of the incident is severe, or if the MRT requires assistance (e.g., death of a patient), employee assistance programs or formal psychological counseling are encouraged2.
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References
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Canadian Patient Safety Institute, Canadian Disclosure Guidelines: Being open with patients and families 2011: Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/disclosure/Documents/CPSI%20Canadian%20Disclosure%20Guidelines.pdf#search=Canadian%20Disclosure%20Guidelines%3A%20Being%20open%20with%20patients%20and%20families. [Accessed 12 Dec 2019]
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Vincent C. Understanding and responding to adverse events. N Engl J Med. 2003;348(11):1051-1056.
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Schwappach DLB, Bolluarte DA. The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability. Swiss Med Wkly 2009;139(1-2):9-15.
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Canadian Medical Protective Association (CMPA). Reporting and responding to adverse events: A medical liability perspective. Available from: https://www.cmpa-acpm.ca/en/research-policy/public-policy/reporting-and-responding-to-adverse-events-a-medical-liability-perspective. [Accessed 12 Dec 2019]