There is now a huge amount of evidence from different countries and across different professional groups that being involved in a patient safety incident, particularly one where the patient is seriously harmed or dies can be very distressing¹. The feelings of guilt, shame, incompetence, anxiety that are reported to be experienced by the healthcare staff involved in these situations are heightened when the individual perceives it was possibly something they did or did not do which caused the patient safety incident. Of the 1,463 doctors we surveyed in the UK², 76% believed the experience of a patient safety incident affected them personally or professionally. 74% reported stress, 68% anxiety, 60% sleep disturbance and 63% lower professional confidence. Moreover, 81% became anxious that they might doing something again in the future which could lead to another patient safety incident.

It is not only doctors who experience physiological distress after involvement in an incident. In another study³we found nurses showed higher levels of distress following a patient safety incident than doctors. For many, the emotional impact of being involved in an incident is short-lived, but for other individuals the effects are long-lasting. In our sample, 8% of doctors reported symptoms associated with post-traumatic stress disorder. This impact on the healthcare employees is the reason the term ‘second victim’ was coined. The emotional impact of being involved when something goes wrong are many, but there are other impacts too which make it so very important that employers, managers and colleagues don’t disregard, ignore, or even punish further the individuals involved.

There is evidence that distress and further loss of confidence can often be exacerbated by the patient safety incident investigation process – and this can lead individuals to burnout, a state of hyper-vigilance and/or the practice of defensive medicine. Some ‘second victims’ may even choose to leave the profession, especially in the absence of timely and tailored support from those around them. From a moral standpoint, supporting people in distress is essential and this includes supporting healthcare employees involved in patient safety incidents. From a healthcare organisational perspective, there is a patient safety, a staff health and well-being, and financial imperative to do so.

To support the NHS to further improve patient safety, NHS England and NHS Improvement are introducing a new Patient Safety Incident Response Framework⁴ (PSIRF). The PSIRF describes a new approach to patient safety incident management, one which facilitates inquisitive examination of a wider range of patient safety incidents “in the spirit of reflection and learning” rather than an approach which feeds into a “framework of accountability”.

Informed by feedback and drawing on good practice from healthcare and other sectors, it supports a systematic and compassionate response to patient safety incidents which is anchored in the principles of openness, fair accountability, learning and continuous improvement. The plan for the introductory version of the PSIRF is for implementation by nationally appointed early adopters during 2021.

The PSIRF outlines how providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted. It clearly sets out how the needs of those affected by patient safety incidents – patients, families, carers and healthcare staff – are met.

Organisations must establish procedures to identify all staff who may have been affected by a patient safety incident and provide access to the support they need. A 2021 Healthcare Safety Investigation Branch national learning report⁵ further highlights the need for support systems for staff. Figure 2 in the report describes some of the approaches which may be offered before and/or after involvement in a patient safety incident.