For Second Victims
“To err is human” Andrew Pope 1711#
The vast majority of people who work in health and social care come to work every day to make a difference in the lives of the people they care for. They aim to provide the very best care they can within highly complex healthcare systems and in the presence of often competing pressures. Sometimes things will and do go wrong.
When things go wrong in healthcare, particularly in combination, this can result in patient harm. A useful analogy (shared by Matt Fogarty, Deputy Director Patient Safety at NHS England & NHS Improvement) to aid the understanding of this concept is the ‘jenga’ tower – removal of one brick may not cause destabilization of the tower but when many bricks are removed consecutively, the tower is compromised and eventually the consequence is a significant incident whereby the tower falls.
In difficult and stressful circumstances where staffing levels are poor, acuity levels are increased, equipment isn’t working, IT systems aren’t communicating and demand is high, consequences are sometimes inevitable. Even when no specific error occurs, sometimes the desired patient outcome isn’t achieved, and this can also impact on any healthcare employees involved. In a survey we conducted, over 50% of the healthcare employees who responded reported being involved in at least one adverse event during their career; with the majority indicating experience of involvement in a patient safety incident.
When a patient is harmed, the primary focus should be on supporting the patient and/or their family, however, the impact on the physical, mental and psychological wellbeing of healthcare staff involved must also be recognised. Sometimes in the aftermath of an incident, the healthcare employees involved are left feeling unsupported and, in some cases feel they are being punished for something they unintentionally did or did not do.
The following diagram demonstrates the process individuals often experience following an adverse event. More detail about each stage is available by clicking on the individual boxes in the diagram.