Manage an adverse event well and you will not have failed your patient
We met whilst talking to medical students about our experiences as patients, sharing what could be learnt from our care. We were both concerned about the culture of fear which we had observed amongst many healthcare professionals. Fear of making a mistake and fear of blame from both their employers and their regulators: fear for their patients and also fear for themselves. We knew that this was something which we wanted to address to protect both patients and families, and those who care for them.
Acknowledging when things go wrong
The vast majority of healthcare professionals go into medicine with good intent. The vast majority care passionately about delivering safe, effective and compassionate care and they are willing to listen and to learn – we have seen this ourselves after we raised concerns. However, it is essential for healthcare professionals to acknowledge the inevitability of something going wrong and to mentally rehearse what they can do to be prepared.
Embedding a just culture within healthcare
We sincerely believe that trust in healthcare can be enhanced after an adverse event if everyone involved is looked after properly, and if the Serious Incident investigation is done well. Both patients and staff want a just culture. We all need psychological safety and we all need care to get through the aftermath when something has gone wrong. All the resources we could find addressed only one point of view (either the impact on staff or the impact on patients) which we felt only increased the barriers between the ‘two sides’ or ‘them and us’ – which was usually more divisive than useful.
Shared humanity and hope
We wanted to make a film in order to draw together the perspectives of both patients and clinicians in the context of managing adverse events in healthcare. It is a considered and deliberate attempt to move away from the adversarial approach which does as much psychological harm as the physical harm which may occur when things have not gone to plan. We made this film to share a message of shared humanity and hope, drawing on our own experiences and by listening to many patients and many healthcare professionals at all levels from a wide range of specialities.
We would love this resource to be used by anyone who appreciates the importance of embedding a just culture within healthcare. We believe that communication, listening, kindness, respect and honesty are all irrevocably intertwined and are essential ingredients for patients, family members and healthcare professionals when adverse events happen in healthcare.
“If you’re not actively working towards learning, you’re actively letting things go wrong”
“Manage an adverse event well and you will not have failed your patient”
You can watch our video and share our message here.