The Quality-Cost Connection: Are you supporting the silent incident victims?
Look after staff involved in adverse events
By Patrice Spath, RHIT
Brown-Spath Associates
Forest Grove, OR
To be personally involved in an adverse patient incident is a very distressing experience. Unsafe situations and poorly designed health care processes can trap even the most competent person into making a harmful mistake. The person who makes a significant error finds that colleagues may try to distance themselves from the event.
Others will be quick to point fingers. Some will be kind and others perfunctory, but the experience undoubtedly will be painful for the clinician. The primary victim of an unsafe health care process is the patient who was harmed.
Often forgotten are the other casualties — those on the frontline of patient care who just happened to be unlucky enough to be at the wrong place at the wrong time. These "silent" incident victims also need our support.
Buried in the intent statement for the Joint Commission on Accreditation of Healthcare Organizations’ leadership standard (LD.5) is a requirement that organizations have defined mechanisms for support of staff who have been involved in a sentinel event.
Support efforts often inadequate
Too often, this requirement is met with a simple statement in the patient safety plan saying that staff will be supported following an incident. But what does this support really entail? If a patient was significantly harmed, it’s quite likely the risk manager will get involved to offer the employee legal advice in the event of a lawsuit. The employee might be asked to tell his or her story at the root-cause analysis investigation, with the assumption that this will be a cathartic experience.
The organization may offer support by not reporting the person’s mistake to the licensing board or professional association or by providing other amnesty opportunities.
These attempts at being supportive are well intended but generally fall short when it comes to looking after the psychological needs of employees personally involved in an adverse event.
It is not surprising that incidents involving patient harm cause enormous emotional distress for the people involved. A sentinel event is outside the range of usual experience for caregivers and therefore has the potential to easily overcome a person’s normal ability to cope with stress. It may produce a negative psychological response in the person who was involved in the incident.
Sometimes, the emotional reactions occur shortly after an adverse event, and sometimes are delayed. The severity of the reactions and the timeframe over which they occur vary from person to person.
It may be difficult for people to recognize their own reactions and acknowledge that they have been through a highly stressful experience. That is why is it important for the organization to have a well-defined process for providing psychological support for people who were involved in or witnessed a sentinel event.
As one risk manager noted following an incident involving an infant abduction, "I wish I had realized the type of emotional support needed by the staff, myself included. It should be mandatory for those immediately involved and made available to others who wish to attend."
Map out a response strategy
Although you’ll be busy with the preliminary event investigation and other risk management concerns, don’t forget the emotional needs of those involved in a sentinel event. Within 72 hours (preferably within 24 hours), hold a meeting to debrief all employees who were directly involved in or who witnessed the sentinel event.
Management and other personnel not directly involved with the incident should not be included in the debriefing session.
It is strongly recommended that attendance at the debriefing meeting be made mandatory. This requirement should be written into your policies and procedures.
A mental health professional or other qualified facilitator should be engaged to assist in the debriefing process. The purpose of the debriefing is to help employees understand some of the reactions they may have and encourage employees to gain support from each other. People must be given an opportunity to verbalize their thoughts and feelings about the incident.
The debriefing should not be used to gather factual information for the root-cause analysis. If participants see the debriefing as a fact-finding mission, they are apt to suppress their feelings and hide or downplay their emotions.
Fact-finding must be done in another setting. The debriefing is intended to take care of employees’ emotional well-being following the trauma of a sentinel event.
A follow-up debriefing with the same professional or facilitator should occur within a couple of weeks. This follow-up session allows employees to discuss any feelings that have come up since the time of the first debriefing and share coping strategies. Employees may be better able to think through their reactions once they have recovered somewhat from the initial shock of the incident.
By this time, employees may be aware of the system problems that contributed to the event. This may create some feelings of anger toward the organization, and these issues need to be explored. This also may be a good time to offer private counseling sessions — perhaps through the organization’s employee assistance program — for people who feel they need additional help. Sentinel events sometimes can trigger memories of painful and unresolved past incidents in an employee’s career, and more assistance from a mental health professional may be needed.
On some occasions following a sentinel event, employees may experience severe emotional stress as a result of the incident. In such cases, it is not appropriate to wait for the debriefing session. Employees who are experiencing severe forms of stress should be encouraged to seek individual therapy as soon as possible after the incident. Individual therapy can be followed by a debriefing session at an appropriate time.
Management should keep a watchful eye on personnel for several weeks, even months, following a sentinel event. Look for signs of irritability, fatigue, negativity, nervousness, poor health or aches and pains, critical and demanding behavior, drug or alcohol abuse, or apathy. If an employee seems to be going downhill, be sure to ask whether he or she has been reflecting on the incident. The employee may need to speak with a professional about it.
Add the human touch
The key to dealing with employees involved in a sentinel event is to ask, "How would I want to be supported if I were in that situation?" To begin with, someone in the organization should say, as soon as possible, that he or she cares and is sorry for what happened. Next, the psychological needs of employees should be addressed through debriefing sessions and, on occasion, individual counseling.
All too often, in our rush to uncover the root cause and deal with negative publicity, the people personally involved in a sentinel event are forgotten. Many medical accident investigation systems are not designed to address the human emotional problems caused by adverse events. It’s no wonder people are reluctant to report their mistakes; especially when they see how the organization treated people involved in past events. Add to your patient safety program a formal and structured process for supporting staff following a sentinel event.
Be sure to explain this process during staff education and training about patient safety. Then, if a significant adverse event actually occurs, follow through with your promise of adequate support.
Employees will embrace the organization’s commitment to patient safety if they see that the goal is to create a safer environment and not destroy the reputations of good people who inadvertently get tripped up by the flaws in the system.
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