Compounded harm – why we should take it seriously

Compounded harm is the extra harm to a patient or healthcare professional from neglecting the emotional and psychological impact of the investigation process after a safety incident

Patient safety is a priority in all healthcare organisations. However, despite this focus on patient safety, adverse events continue to happen, with approximately 10 per cent of all patients availing of healthcare services worldwide sustaining some degree of harm arising from the provision of those services. Given this frequency, it is vital that healthcare practitioners and organisations respond in a way that does not compound the harm to either the patient or the healthcare practitioners, who also can be adversely affected by these regrettable incidents.

What is compounded harm?

Compounded harm occurs when the investigation of a patient safety incident ignores the human relationships and the psychological impact the incident and the subsequent investigation can have on patients or healthcare staff.  This can happen if the investigation is perceived as closed or defensive, if parties feel unheard, or if concerns are not validated. Such oversights diminish the effectiveness of any restorative processes that may follow the investigation. Once recognised, putting processes in place to minimise the occurrence and impact of such compounded harm can go a long way to minimising additional harm from the investigation process or system following an adverse incident.

Adversarial conditions may impair communication and can reduce opportunities to bring patients, families and health providers together. People receiving and providing healthcare are hurt and relationships can be adversely affected if human considerations following a patient safety incident/investigation are not addressed. Feelings of shame, contempt, betrayal, disempowerment, abandonment, or unjustified blame can be left to intensify over time. Keeping parties apart compounds the harm since dialogue and good communication is needed for healing. It is important to understand what is causing the compounded harm and acknowledge its impact on the health and wellbeing of the people who are affected.

A number of relevant changes have been introduced in the last number of years, affecting how patient safety concerns are dealt with. These changes are aimed at improving patient safety, promoting good communication, facilitating system review, and improving patient care going forward, all of which should hopefully lessen the likelihood of compounded harm occurring.

Patient Safety Act

One such notable recent change is the enactment of the Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023, which has not yet commenced. The Act aims to further embed openness and transparency across the Irish healthcare system. It provides a legislative framework for a number of important patient safety issues, including the mandatory open disclosure of a list of specified serious patient safety incidents that must be disclosed to the patient and/or their family and the notification of the same to HIQA, Chief Inspector of Social Services and the Mental Health Commission.

Open disclosure is defined as an open, consistent, compassionate, and timely approach to communicating with patients and, where appropriate, their relevant person following patient safety incidents. It includes expressing regret for what has happened, keeping the patient informed, and providing reassurance in relation to ongoing care and treatment, learning and the steps being taken by the health services provider to try to prevent a recurrence of the incident. (HSE 2019)

The Patient Safety Act 2023 introduces mandatory disclosure requirements for healthcare providers in the event of a serious incident. Available at: www.irishstatutebook.ie/eli/2023/act/10/enacted/en.

In addition, the Guide to Professional Conduct and Ethics for Registered Medical Practitioners (ninth edition, 2024) was also published this year and includes the following guidance with regard to a patient safety incident:

2.2 Where an unintended and unanticipated outcome occurs, you must: Make sure that the effect on the patient is minimised as far as possible and that they receive further appropriate care as necessary. Facilitate timely and compassionate open disclosure and support the patient through this process. Report the incident, learn from it, and take part in any review of the incident.

It is clear that these developments encourage an open honest alliance between patients and healthcare professionals. This applies to the provision of care, but also the conversations and processes that follow unanticipated or adverse outcomes. Holistic patient care not only applies to diagnostics and treatment, but also to the management of patient expectations and the difficult conversations when something goes wrong. Communication and support are key for patients and healthcare professionals to minimise compounded harm that can result from the process of information gathering, investigation, and presentation of findings.

In the UK, the Harmed Patients Alliance conducted a survey asking how those harmed by their contact with healthcare felt about the response they had received and how it impacted them. The majority (80 per cent) of people felt they had not been “seen and heard” as if they truly mattered. As well as honesty and openness about what had happened, people also commented that it was important to experience compassion and receive acknowledgement and understanding of their perspective and experience. Healing and rebuilding of relationships were also important to them.

How do we reduce the risk of compounded harm?

Research has found that a restorative approach, which includes all the affected parties, has the potential to result in a more meaningful apology and this in turn may reduce the incidence of compounded harm. A restorative approach focuses on the needs of the people who have been hurt and how relationships can be repaired, as well as those changes to prevent similar incidents from happening. The focus is on humanising harm and the equal importance of healing and learning following the investigation of an adverse event.

On the same theme, the idea of ‘kindness’ seems to feature strongly at international safety and quality conferences and kindness is often used interchangeably with empathy and compassion.

Could kindness be at the heart of reducing compounded harm to the patient or the healthcare practitioner following a patient safety incident?

Most doctors spend years honing their technical skills, but a focus on ‘soft skills’ and kindness is a choice of action we can all elect to take. There seems to be a compelling link between compassion in healthcare leadership and staff wellbeing and better outcomes for patients. A continued focus on communication skills throughout our careers is required and poor communication skills are a common finding in many patient complaints and claims. The basic skills of listening, showing empathy, checking patient understanding and providing clear explanations are essential tools required for all patient interactions.

Conclusion

In summary, compounded harm is the additional harm that can be experienced by a patient or healthcare professional resulting from inadequate consideration for the emotional and psychological impact of the process of investigation following a patient safety incident. It can result in additional negative effects on mediation, restoration, and doctor-patient relationships. The humanisation of the investigative process through empathic accessible communication, adequate support, and a restorative approach to incident investigations have been suggested to reduce the risks associated with compounded harm.

Medisec is a not-for-profit membership organisation and is owned by our medical and dental practitioner members in Ireland. In addition to arranging professional indemnity insurance for our members, we also provide round-the-clock assistance, support, and expert advice to our members when they need it most. We would always recommend you contact your indemnifier for advice and support if you have been involved in a patient safety incident.