1. Seeing safety through the patient’s eyes The trajectory of harm Charles Vincent Department of Experimental Psychology, Nuffield Department of Surgical Sciences University of Oxford

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

3. 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)

4. Harm through the patient’s eyes u Harm is conceived very broadly encompassing both serious disruption of treatment and distressing events. u Harm includes serious failures to provide appropriate treatment as well as harm that occurs over and above the treatment provided. u 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.

5. What do we mean by harm? u Treatment specific harm u Harm due to over treatment u General harm from healthcare u Harm due to failure to provide appropriate treatment u Harm due to failed or inadequate diagnosis u Psychological harm and feeling unsafe u Harm due to neglect and dehumanisation

6. Explore dimensions of harm in each setting u Hospital acquired syndromes in care of the elderly – Dehydration – Malnutrition – Delirium – Depression – Pressure sores – Incontinence

8. The Aftermath Reducing harm, restoring trust

9. Trauma in a medical context u Patients may be traumatised in two ways – By the original event – By the way it is handled afterwards u Patient is harmed (unintentionally) by those in whom they placed great trust u Patient is cared for in environment in which trauma occurred u Long term effect of injuries seldom seen by those who caused them

10. Why do patients sue their doctors? u Explanation and apology u Accountability u Prevention u Compensation Vincent, Young & Phillips Lancet, 1994

11. Open Disclosure u Australian Open Disclosure Project u JCAHO Standards u US National Patient Safety Foundation u Kaiser Permanente and VA Hospitals u Canadian Disclosure Guidelines u UK National Patient Safety Agency

12. Helping patients and families u 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

13. Beyond disclosure u Ask specific questions about both physical injuries and emotional trauma u Consider therapy for trauma u Inform patients of changes u Consider long term implications and support

14. “...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) u Guilt u Crisis of confidence u Surgical practice affected u Rumination u Anxiety u Interference with personal life

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

16. Caring for patients, supporting staff u Some progress in a more open and proactive approach u Some powerful examples of work with families after tragic events u More understanding and support for staff u Much more to be done but huge potential benefits for both patients and staff