The Essentials of Patient Safety - Clinical Human Factors Group

The Essentials of Patient Safety
Acknowledge error. The potential for error in medicine, as in other activities,
needs to be recognized and openly acknowledged. Education about the ubiquity
of error, its causes and likely consequences, would promote a more realistic
attitude and constructive approach.
Openness about error. Open discussion of error, particularly by respected senior
figures, is very powerful because it provides a mandate for such discussions to
occur at other times. In effect, the junior nurse or doctor learns that it is
acceptable to discuss errors openly because their seniors do it.
Open disclosure. An agreed policy on openness is a critical for staff as for
patients. Many staff are still torn between their own desire for a more open
stance and the more cautious approach that they perceive to be demanded, rightly
or wrongly by managers and colleagues.
Training in disclosure. Training in disclosing and explaining error is critical.
Facing a patient harmed by treatment, or their naturally distressed and angry
relatives, is a particularly difficult clinical situation for which little guidance or
training is available. Both patients and staff will benefit if clinical staff have
some training in helping dissatisfied, distressed, or injured patients and their
relatives.
Formal and informal support. Understanding and acceptance from colleagues is
always important but sometimes people need more than general support and
expressions of confidence. The range of potential support extends from a quiet
word in a corridor to the offer of extended psychotherapy. Sometimes a private
discussion with a colleague or a senior figure will be sufficient; some hospitals
employ recently retired senior doctors as mentors.
Few organisations however have put staff support service into practice in an organised
and effective way or fully understood the need for such a service. Brigham and
both patient and staff support that has its origins in a near disaster in 1999 in which
Linda Kenney, the founder of Medically Induced Trauma Support Services, experienced
a grand mal seizure during an operation. Linda Kenney and Frederick van Pelt, the
anaesthetist involved, began in parallel to establish support services for patients and a
peer support programme for clinical staff. The staff support programme aims to
recruit credible, experienced clinical staff with personal understanding of the impact
of error who are immediately available to provide confidential reflection and support.
In addition to an active commitment to disclosure and apology, Brigham and
Hospital has started to develop an Early Support Activation (ESA) with
MITSS for patients and families in conjunction with
social services and patient relations. The long-term strategy is to have a
comprehensive emotional support response for patients, families and care providers
(9).
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