Seeing safety through the patient’s eyesThe trajectory of harm

Charles Vincent Department of Experimental Psychology, Nuffield Department of Surgical Sciences

University of Oxford

Overview

Seeing harm through the patient’s eyes The aftermath Looking after patients, families and staff

Patient harm happens in every healthcare setting: at home in convalescence, in the nursing home, in an operating room under

anaesthesia, at the lab getting blood drawn, in the hospital corridor lying alone on a stretcher ……

Harm may result from wrong or missed diagnosis, scheduling delay, poor hygiene, mistaken identity, unnoticed symptoms, hostile behaviour, device malfunction, confusing instructions, insensitive language and hazardous

surroundings.

The trajectory of harm begins with the unexpected experience of harm arising from or associated with the provision of care, including acts of both commission and omission. …..The patient may experience harm during the

episode of care when the failure occurred, or later, after some time has passed. (Canfield, 2013)

Harm through the patient’s eyes

Harm is conceived very broadly encompassing both serious disruption of treatment and distressing events.

Harm includes serious failures to provide appropriate treatment as well as harm that occurs over and above the treatment provided.

Harm is seen not in terms of incidents but as a trajectory within a person’s life. Both the genesis and consequences of harm occur over time.

What do we mean by harm?

Treatment specific harm Harm due to over treatment General harm from healthcare Harm due to failure to provide

appropriate treatment Harm due to failed or inadequate diagnosis Psychological harm and feeling unsafe Harm due to neglect and dehumanisation

Explore dimensions of harm in each setting

Hospital acquired syndromes in care of the elderly– Dehydration – Malnutrition– Delirium – Depression – Pressure sores – Incontinence

The AftermathReducing harm, restoring trust

Trauma in a medical context

Patients may be traumatised in two ways– By the original event– By the way it is handled afterwards

Patient is harmed (unintentionally) by those in whom they placed great trust

Patient is cared for in environment in which trauma occurred

Long term effect of injuries seldom seen by those who caused them

Why do patients sue their doctors?

Explanation and apology Accountability Prevention Compensation

Vincent, Young & Phillips Lancet, 1994

Open Disclosure

Australian Open Disclosure Project

JCAHO Standards US National Patient

Safety Foundation Kaiser Permanente and

VA Hospitals Canadian Disclosure

Guidelines UK National Patient

Safety Agency

Helping patients and families

Requires clinical and organisational commitment– To openness, honesty and fairness– Believe people who say their treatment has

harmed them– Continuing duty of care– Financial assistance and practical help

Beyond disclosure

Ask specific questions about both physical injuries and emotional trauma

Consider therapy for trauma Inform patients of changes Consider long term implications and support

“...repairing someone's aneurysm, giving them a stroke and then rendering them paraplegic it

would be a terrible outcome …….The impact on the patient, the impact on the

patient's family. Death, limb loss, paralysis, they're huge and affect the impact of

complication on your emotions...” (23, consultant)

Guilt Crisis of confidence Surgical practice affected Rumination Anxiety Interference with personal

life

Supporting Staff

Acknowledging the potential for `error’ Understanding the causes of adverse events Education about law and the legal process Formal and informal support How to communicate with injured patients Agreed policy and strong organisational backing!

Caring for patients, supporting staff

Some progress in a more open and proactive approach

Some powerful examples of work with families after tragic events

More understanding and support for staff Much more to be done but huge potential benefits

for both patients and staff