People who work in healthcare, like the rest of us, make mistakes. If someone flicks on the indicator to turn left in the car but accidentally turns on the wipers, or goes upstairs to find socks and then completely forgets why they are there then this is mildly inconvenient. In healthcare these same mistakes, particularly in combinations, can result in patient harm. In difficult and stressful circumstances where staffing levels are poor, equipment isn’t working, IT systems aren’t communicating and demand is high, mistakes are sometimes inevitable. Even when no specific mistake is made, sometimes the patient outcome we would want isn’t achieved, and this can also impact clinicians.
Of course, when a mistake happens and a patient is harmed, the focus should be on supporting the patient and/or their family, keeping them involved in what is going on and doing everything we can to avoid further harm. Sometimes, though, the person/people who make the mistake/s are left unsupported and, in some cases are punished (directly or indirectly) for something they did not intend to do. Almost no-one goes to work intending to harm a patient and yet in a survey we conducted, over 50% of the sample reported being involved in at least one adverse event during their career; the majority had experienced some kind of patient safety incident. So, as you read through the information on this site remember you are not alone. The feelings you might be experiencing are difficult to deal with but they will get easier. Many of the people in our survey were able to make changes to their own practice or the processes and organisations in which they worked to try to stop the same thing happening again. The people we spoke to (see videos) all mention the importance of talking to those around them about what happened and how they felt. This can also lead to positive change for you and your team.
The following diagram demonstrates the process that people often experience following an adverse event. More detail about each stage is available by clicking on the individual boxes in the diagram.
