Pharmacy Daily | Clinicians the second victims of errors

GREATER support needs to be given to health practitioners in the wake of medication errors, Society of Hospital Pharmacists of Australia (SHPA) Medication Safety Leadership Committee member, Kerry Fitzsimons, believes.

In a statement issued to mark the 2022 World Health Organization's Patient Safety Day, earlier this week, Fitzsimons noted that it was important to "highlight the need to care for all peope who are impacted by mistakes and errors, especially if they result in patient harm".

"Too often I have heard, 'who would make such a mistake?', or 'that doctor/nurse/pharmacist should not be working as they make mistakes', or 'this incident has been the result of someone not concentrating properly', resulting in labelling the health professional at the centre of the incident as incompetent and to blame for the error," she said.

"At the time the incident occurs, there may be no recognition of something going wrong.

"It is only after the patient suffers complications as a result of the medication error, that there is a realisation of failure and guilt in response to being part of the cause.

"The main victims of medication errors are the patients and their families.

"The second victim - the health care worker - may have a curtain of blame from their organisation and peers which can cause the person(s) involved psychological harm, guilt, and a significant emotional toll.

"After making an error an intense period of professional and personal anguish may follow, even among the 'strongest' caregivers.

"The impact can be devastating, and some instances result in loss of career or even loss of life.

"It is important to raise awareness of the second victim phenomenon and ensure a proactive response in supporting health professionals involved with medication incidents.

"Promotion of a 'Just Culture' versus a 'Blame Culture' environment will help promote clinician healing and recovery from the second victim experience.

"The promotion of healthcare workers' wellbeing improves staff morale, leads to fewer medical errors, and is critical in protecting and supporting future clinicians from emotional trauma experienced after unanticipated clinical events."