The Essentials of Patient Safety - Clinical Human Factors Group

The Essentials of Patient Safety
Supporting staff after serious incidents
Human beings make frequent errors and misjudgements in every sphere of activity, but
some environments are less forgiving of error than others. Errors in academia, law or
architecture, for instance, can mostly be remedied with an apology or a cheque. Those in
medicine, in the air, or on an oil rig may have severe or even catastrophic consequences.
This is not to say that the errors of doctors, nurses or pilots are more reprehensible, only
that they bear a greater burden because their errors have greater consequences. Making
an error, particularly if a patient is harmed because of it, may therefore have profound
consequences for the staff involved, particularly if they are seen, rightly or wrongly, as
primarily responsible for the outcome. The typical reaction has been well expressed by
You feel singled out and exposed - seized by the instinct to see if anyone has
noticed. You agonize about what to do, whether to tell anyone, what to say.
Later, the event replays itself in your mind. You question your competence but
fear being discovered. You know you should confess, but dread the prospect of
potential punishment and of the patien(5).
Junior doctors single out making mistakes, together with dealing with death and dying,
relationships with senior doctors and overwork, as the most stressful events they have to
deal with (6). Medical students anticipate the mistakes they will make as doctors even
before entering medical school:
responsibility you have and that human error happens all the time. I thought
about it even before I decided that I definitely wanted to go to medical school
(7).
In a series of in depth interviews with senior doctors Christensen and colleagues (8)
discussed a variety of serious mistakes, including four deaths. All the doctors were
affected to some degree, but four clinicians described intense agony or anguish as the
reality of the mistake had sunk in. The interviews identified a number of general themes:
the frequency of mistakes in clinical practice; the infrequency of self-disclosure about
mistakes to colleagues, friends and family; and the emotional impact on the physician,
such that some mistakes were remembered in great detail even after several years. After
the initial shock the clinicians had a variety of reactions that had lasted from several days
to several months. Some of the feelings of fear, guilt, anger, embarrassment and
humiliation were unresolved at the time of the interview, even a year after the mistake.
Strategies for coping with error, harm and their aftermath
Many of the doctors interviewed in these various studies study had not discussed the
mistakes or their emotional impact with colleagues. Shame, fear of humiliation, fear of
punishment all acted to deter open discussion and isolate people from their colleagues.
Hopefully, as patient safety evolves, healthcare staff will be able to be more open about
error and more open about their need for support when errors do occur. While there is
little formal guidance, and almost no research on this topic, the following suggestions
may be useful.
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