Mitigation
The treatment and remediation of physical problems is obviously necessary when a patient has suffered some harm or complication. However psychological support is equally important both for patients and staff. Organisations vary hugely in the extent to which they are willing, prepared and able to provide support emotionally, practically and financially. Some hospitals have very well established systems for responding when patients have been harmed and highly developed mitigation strategies; others simply react and adapt.
Support Systems for Staff and Patients
The basic needs of injured patients have been understood for 20 years. We would all, in varying degrees, like an apology, an explanation, to know that steps had been taken to prevent recurrence and potentially financial and practical assistance (Vincent et al. 1994). We know that staff suffer a variety of consequences from being the 'second victim' as Albert Wu eloquently expressed it, not implying that the experiences of staff were necessarily comparable to those of injured patients (Wu 2000). We should also consider that a member of staff who has been seriously affected may well be performing poorly and be a risk to future patients; this again is rarely addressed. There are a few pioneering examples of programmes of support for both patients and staff (Box 7.2) but this is an area of safety management which needs substantial development (Iedema et al. 2011).
Box 7.2. Medically Induced Trauma Support Services (MITSS)
Linda Kenney, the founder of MITSS, experienced a grand mal seizure during an operation while cared for by an anaesthetist, Frederick van Pelt. Together they founded MITSS which provides support for both patients and staff. The Peer Support Programme uses colleagues as the primary support, following an approach that has been successfully used in the police, fire and emergency medical services. The programme aims to recruit credible, experienced clinical staff with personal understanding of the impact of error who are immediately available to provide confidential reflection and support. An education and training programme runs in parallel that aims to challenge the culture of denial of emotional response to serious errors and events. The hospital concerned made an active commitment to disclosure and apology and developed an Early Support Activation (ESA) programme for patients and families. The long-term strategy is to have a comprehensive emotional support for patients, families and care providers (van Pelt 2008).
The University of Michigan Health System pioneered a programme which included both support for patients and staff but also active intervention to provide compensation if appropriate and reduce the need for costly and potentially acrimonious litigation. The organisation performs active surveillance for medical errors, fully discloses errors to patients, and offers compensation when it is at fault. Evaluation of the programme found a decrease in new legal claims, number of lawsuits per month, time to claim resolution, and costs after implementation of the program of disclosure with offer of compensation. This approach did not increase legal claims and costs even in the notoriously litigious United States (Kachalia et al. 2010); in fact some decline in litigation was reported in Michigan generally through the latter part of the study period. Several New York hospitals have now implemented similar 'communication and resolution programmes'. To be successful they require the presence of a strong institutional champion, investment in developing and marketing the program to sceptical clinicians, and making it clear that the results of such transformative change will take time (Mello et al. 2014).
