Introduction:
Every healthcare professional must face the fact that he or she will encounter some sort of adverse event or medical error in his or her career. Therefore, it is essential to take a closer look at the needs of patients and their relatives after an adverse event. We also need to take into account the consequences for the individual healthcare provider or medical team directly involved in the adverse event.

Patients, their families and health-care providers all suffer from these events. Taking care of patients and their families or support persons after an incident is an ethical duty and an important element of how adverse events are handled effectively. Thus, significant commitment is required from health-care organisations to develop frameworks for effective communication between health-care providers and patients and their families to take place and to support health-care providers in this process.

The questions being explored in the following discussion are:

• How do health-care providers respond to critical incidents?
• What do health-care providers need after critical incident involvement?
• What do patients and their families expect after a critical incident?
• What characterises effective disclosure?
• What is the current practice of open disclosure?
• How can health-care organisations meet the needs of health-care providers and patients after critical incidents?

Health-care providers’ response to critical incidents:

• Healthcare professionals involved in a medical error can experience their own emotional reactions that can often lead to a personal crisis. Studies show that critical incidents do have serious impact on health-care providers, such as negative emotional responses, psychological distress, serious health effects and performance decrements (Ref: 1-5)

 

• Emotional responses reported frequently include distress, fear, self-doubt, feelings of failure and inadequacy, shame and guilt (Ref: 6-11)

• Physicians were reported to be severely impaired in their professional performance after they have been involved in a medical error. This impairment led to reduced efficiency and increased the risk for further error (Ref: 12)

 

 

So what do physicians need after an adverse event?

• Support must be provided to healthcare professionals in their acceptance of the responsibility for an error. This can lead to important lessons being learned from these events and ultimately to an improvement in an individual’s performance.

 

• Discussing the critical incident with a trusted colleague helps immensely to overcome the emotional burden associated with an adverse event.

Patient expectations and the effect of open disclosure after the event:

• Across health-care domains, studies show that open disclosure after critical incidents is crucial from the perspective of patients and their families.

 

• It has recently been argued that open disclosure – particularly a full apology that consists of an admission of responsibility, may help in the recovery and health of patients after a critical incident. However, systematic studies on the psychological and physiological effects of open disclosure on recovery and health are lacking.

Four main reasons for litigation against health-care providers include:

• Accountability (i.e., wish to see staff disciplined)
• Explanation (i.e., wanting an explanation and not wanting to be ignored)
• Standards of care (i.e., ensuring that a similar incident never happens again)
• Financial compensation

 

Reasons for taking legal actions (Ref: 13)

Reasons for litigation	Percent of respondents who agree
So that it would never happen again	91.4
I wanted an explanation	90.7
I wanted the doctors to realise what they had done	90.4
To get an admission of negligence	86.7
So that the doctor would know how I felt	68.4
My feelings were ignored	66.8
I wanted a financial compensation	65.6
Because I was angry	65.4
So that the doctor did not get away with it	54.7
So that the doctor would be disciplined	47.6
Because it was the only way I could cope with my feelings	45.8
Because of the attitude of the staff afterwards	42.5
To get back at the doctor involved	23.2

 

 

Recommendations for open disclosure:

• The first and most important aspect following an adverse incident is the safe care of the patient.
• With regard to provision of anaesthesia, the same team should continue to provide the patient’s care.
• Each member of the team involved in the adverse incident should record a detailed narrative as part of their own notes as soon as possible after the adverse event has occurred, and all drugs, equipment and supplies should be kept for further investigation.
• As soon as possible or when appropriate to do so, the patient and/or relatives should be informed about what has happened. During this conversation, the focus should be to explain the events that have occurred and to indicate the next steps that will be taken.

 

What characterises effective disclosure?

• Accurate and timely information is a key element of open disclosure. Patients and their families need to understand what happened and what to expect in terms of immediate consequences and appropriate remedial action.
• Unsatisfactory explanations have been shown to increase distress and hinder psychological adjustment.
• Silence of health-care providers has been interpreted by some patients and families as hiding information.
• Disclosure can be a relief for health-care professionals as well.

 

What is the current practice of open disclosure?

• As stated by the American College of Physicians “Errors do not

necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may.”

• Despite the wide acknowledgement of the ethical duty to disclose, evidence suggests that open disclosure may be uncommon, not always very systematic and that there is substantial variation in what health-care providers decide to disclose (Ref: 14-20)

 

• The current practice of open disclosure is not only a result of clinicians’ attitudes and fears but also of barriers at the organisational level. Thus, failure to disclose is a systemic problem that needs to be addressed at multiple levels.

Current concepts of dealing with adverse events in hospitals:

• Morbidity and mortality (M&M) conferences provide a forum to discuss and learn from adverse events as long as the discussion concentrates primarily on what happened instead of who was guilty.

 

• When M&M conferences are conducted in a responsible manner, they can provide opportunities for young residents to learn how to talk about errors associated with delivery of care to patients.

• Furthermore, this permits residents to be able to identify reliable and trustworthy seniors in their department that they might approach and talk to if they had been directly involved in an adverse incident.

 

 

Organisational approaches for the support of staff after a medical error has occurred:

The ‘Swiss Foundation for Patient Safety’ has published guidelines describing the actions to take after an adverse event has occurred (Ref: 21)

Recommendations for senior staff members

• A severe medical error is an emergency and must be treated as such (by being given absolute priority). It can have a severe emotional impact for the team involved.

• Confidence between the senior staff and the professional involved as well as empathic leadership are important prerequisites for the review of the adverse event.

• Professionals directly involved with the adverse event need a professional and objective discussion as well as emotional support with peers in their department.

• Seniors should offer support to assist with the disclosure conversation with the patient and/or the relatives and for further clinical work in cases where the Professionals involved might feel insecure in their daily work.

• A professional review of the case based on facts is important for analysis and to provide an opportunity to learn from a medical error.

 

 

 

Recommendations for colleagues

• Be aware that such an adverse event could happen to you.

• Offer time to discuss the case with your colleague. Listen to what your colleague wants to tell and support him/her with your professional expertise.

• Address any culture of blame either directly from within the team or by any other colleagues.

• Take care of your colleague and be mindful of any feelings of isolation or withdrawal he or she may be experiencing.

 Recommendations for healthcare professionals directly involved in an adverse event

• Do not suppress any feelings of emotion you may encounter after your involvement in a medical error.

• Talk through what has happened with a dependable colleague or senior member of staff. This is not weakness. This represents appropriate professional behaviour.

• Take part in a formal debriefing session. Try to draw conclusions and learn from this event.

• If possible talk to your patient/their relatives and engage with them in open disclosure conversations.

• If you experience any uncertainties regarding the management of future cases seek support from colleagues or seniors.

Conclusion:

Morbidity and mortality conferences should be conducted fruitfully to discuss and learn from adverse events. These conferences should support an open and truthful dialogue among experienced professionals and should avoid a culture of blame, accusation and punishment. When morbidity and mortality conferences are conducted in a responsible manner, they can provide opportunities for young residents to learn how to talk about errors associated with delivery of care to patients. Furthermore, this permits residents to be able to identify reliable and trustworthy seniors in their department who they might approach and talk to if they had been directly involved in an adverse incident.

 

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