Managing the Patient Safety Incident Aftermath

Healthcare is an inherently high-risk, high-stakes activity. Despite rapid advances in science, technology, and systems of care, Patient Safety Incidents (PSIs), and even Never Events, remain inevitable. When things ‘go wrong’, concern for the welfare of patients and their families should rightly be at the centre of our concern. However, those involved in delivering care, the clinicians at the “sharp end”, can also suffer, sometimes with serious adverse consequences. This talk explores what getting it wrong means for clinicians, why our responses to PSIs are sometimes unhelpful, and how we might do better for both patients and staff.

The talk draws extensively on first-hand experience as a consultant anaesthetist and intensivist, clinical governance lead, team skills trainer, and author of multiple patient safety reviews and coroner’s reports. It also incorporates anonymised narratives from colleagues across career stages who have been involved in a wide variety of patient safety incidents. These accounts reveal consistent themes: shock, guilt, loss of confidence, fear of professional consequences, and the long “tail” of incidents extending through complaints, litigation, inquests, and investigations.

Central to the discussion is the so-called Second Victim Phenomenon, first articulated by Wu (BMJ, 2000), describing the psychological harm experienced by healthcare workers involved in PSIs. The evidence suggests that reflective, conscientious clinicians may be particularly vulnerable. While modern patient safety frameworks such as PSIRF emphasise learning and systems thinking, organisational responses often remain inconsistent, delayed, or inadvertently harmful, leaving support to the goodwill of colleagues.

The talk aims to illustrate what can help afterwards: early human contact, peer support from those with lived experience, honest conversations, proportionate governance processes, understanding and patience from the employer and recognition that recovery takes time.

The session concludes with practical, experience-informed suggestions for clinicians, teams, and organisations on how to respond when things go wrong, and why looking after colleagues is not optional, but essential for safe, sustainable healthcare.

Key message:

We will continue to make mistakes. We cannot change the past—but how we respond to it determines learning, trust, and the future wellbeing of both patients and professionals.

References

• Medical error: the second victim. The doctor who makes the mistake needs help too. Wu, A, BMJ 2000;320:726–7

• Discontinuity and Disaster: Gaps and the Negotiation of Culpability in Medication Delivery. Sidney Dekker, Journal of law, medicine & ethics, 2007 Fall, p463.