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The goal of the NPSIF is to improve patient safety at all levels of healthcare across all modalities of healthcare provision, including prevention, diagnosis, treatment and follow up within overall context of improving quality of care and progressing towards UHC (Universal Health Coverage) in the coming decade. The scope of patient safety applies to all national programmes and envisages collaboration of wide range of national international stakeholders both within and outside health sector. NPSIF applies to national and sub-national levels as well as to public and private sectors. Objectives: Strategic Objective 1: To improve structural systems to support quality and efficiency of healthcare and place patient safety at the core at national, subnational and healthcare facility levels. Strategic Objective 2: To assess the nature and scale of adverse events in healthcare and establish a system of reporting and learning. Strategic Objective 3: To ensure a competent and capable workforce that is aware and sensitive to patient safety. Strategic Objective 4: To prevent and control health-care associated infections. Strategic Objective 5: To implement global patient safety campaigns and strengthening Patient Safety across all programmes. Strategic Objective 6: To strengthen capacity for and promote patient safety research.

“After he died, the little plastic ID band that was around his tiny wrist should have been slipped onto mine. There was nothing more that could have been done for him, but there was plenty that needed to be done for me. I needed an infusion of truth and compassion. And the nurses and doctors who took care of him, they needed it too." Leilani Schweitzer[1] When someone is hurt, it is reasonable to expect the healthcare system to provide care to alleviate symptoms or to cure. It is also reasonable to expect those providing the care to be adequately trained and supported to do so. Yet, when harm is caused by healthcare, the spectrum of harm suffered is not well understood, care needs are not fully recognised and, therefore, the care needed to facilitate optimum recovery is not being provided.[2] In fact, with outrageous frequency, at a time when exceptional care is so desperately needed, those hurting describe how they are further harmed from ‘uncaring’ careless and injurious responses. Healthcare harm is a ‘double whammy’ for patients Healthcare harm is a ‘double whammy’. There’s the primary harm itself – to the patient and/or to those left bereaved – but there is also the separate emotional harm caused specifically by being let down by the healthcare professionals/system in which trust had to be placed.[3] This additional emotional harm has been described as being the damage caused to the trust, confidence and hope of the patient and/or their family.[4] Trust – you rely on professionals to take responsibility for what you cannot do yourself. Confidence - you believe that the system will protect you from harm. Hope – you have the conviction that things will turn out well. Anderson-Wallace and Shale[4] For the patient and family to be able to heal from healthcare harm, appropriate care must be provided not only for the primary injury and any fall out from this, but also this additional emotional injury (being let down by healthcare) and any fall out from that. For example, a parent who loses a child as a result of failures in care will need help to cope with the loss of their child and all of the processes that occur as a result. But they will also need support to cope with having had to hand over responsibility for their child’s safety to healthcare professionals, only to be let down, and all the feelings and processes associated with that. Much needs to happen to restore that parent’s trust, confidence and hope in our healthcare system and the staff within it. This is different to the parent of a child who has passed away from an incurable illness despite exemplary healthcare. A parent let down by healthcare has specific additional care and support needs that need to be met to help them cope and work towards recovery. Healthcare harm also causes emotional harm to the staff involved In 2000, Albert Wu introduced the phrase ‘second victim’ in an attempt to highlight the emotional effects for staff involved in a medical error and the need for emotional support to help their recovery.[5] The term has recently been criticised, since families should be considered the second victim,[6] and the word victim is believed “incompatible with the safety of patients and the accountability that patients and families expect from healthcare providers.”[7] While the term itself may be antagonistic, or misrepresentative, the sentiment – that staff involved in incidents need support to cope with what has happened, and to give them the confidence to do what is needed to help the patient/family heal – certainly stands. When staff are involved in an incident of patient harm, they may lose trust in their own ability and the systems they work in to keep patients safe, and they may worry about their future.[5],[8] They need care and support in order to recover themselves and, crucially, so that they feel psychologically safe and are fully supported to be open and honest about what has happened. They need to feel able to do this without fearing personal detrimental consequences for being honest, such as unfair blame or a risk to their career. This is essential to the injured patient/family receiving the full and truthful explanations and apologies they need in order to regain trust, confidence and hope, and, ultimately, to heal as best they can. So, in addition to patients and families there should be a ‘care pathway’ for staff involved in incidents of harm. A google search on ‘second victim’ reveals a wealth of research on the emotional effects of medical error for staff involved and the best ways to provide support for this, and this is resulting in the emergence of staff support provision to aid recovery.[9] In contrast, very little research has been done into the emotional effects and support needs of families and patients. How is ‘care’ for emotional harm given? The ‘treatment’ of the emotional harm has been described as ‘making amends’ – by restoring trust, confidence and hope.[4] Once a patient has been harmed by healthcare, every interaction (physical, verbal or written) they have with healthcare after that will either serve to help them heal or to compound the emotional harm already suffered. Trew et al.[10] describe harm from healthcare as a “significant loss” and conclude that “coping after harm in healthcare is a form of grieving and coping with loss”. In their model, harmed patients and families proceed through a ‘trajectory of grief’ before reaching a state of normalisation. Some can move further into a deeper stage of grief and seemingly become stuck in what is referred to as complicated grief. They can display signs of psychiatric conditions "if there are substantial unresolved issues, or where there is unsupportive action on the part of individuals associated with the healthcare system and the harm experience”. At the point of the harmful event, the patient/family experiences losses, including a drop in psychological wellbeing. From this point on, healthcare staff and organisations have opportunities to respond. If the response is supportive it may be helpful for the patient/family in coping with the losses. If the response is not supportive, this may cause ‘second harm’ complicating the healing process, leaving the patient/family with unresolved questions, emotions, anger and trust issues. The patient’s psychological wellbeing and ability to return to normal functioning are severely affected. “Most healthcare organizations have proved, in the past at least, extraordinarily bad at dealing with injured patients, resorting at times, particularly during litigation, to deeply unpleasant tactics of delay and manipulation which seriously compounded the initial problems. My phrase ‘second trauma’ is not just a linguistic device, but an accurate description of what some patients experience.” Charles Vincent[11] There is no shortage of individuals who have suffered extensive ‘second harm’ sharing their experiences in the hope this will lead to better experiences for others and some help for themselves to recover. Many are, wrongly, being ‘written off’ as historical cases that can no longer be looked at. This cannot be right – when these people are suffering and need appropriate responses to heal their wounds. The extent of suffering that exists now, in people who have been affected by both primary trauma and then second harm from uncaring defensive responses, or responses that have not taken into account the information patients and families themselves have, or relevant questions they ask, is no doubt nothing short of scandalous. There is a pressing urgency for the NHS to stop causing secondary trauma to affected patients and families. ‘Patient safety’ has to start applying to the harmed patient and their family members’ safety after an adverse event, and not just focus on preventing a repeat of the event in the future. Yes, future occurrences must be prevented, learning is crucial, but so is holistically ‘looking after’ all those affected by this incident. If they are not looked after, their safety is at risk as their ability to heal is severely compromised; in fact they are in danger of further psychological trauma. These same principles apply to affected staff. Avoiding second harm: what happens now and what is needed? This series of blogs will highlight that every interaction a harmed patient or family member has with staff in healthcare organisations (not just clinical staff) after a safety incident should be considered as ‘delivery of care’. With this view, the ‘care interaction’ should be carried out by someone trained and skilled and supported to do so, with the genuine intention of meeting the patient/families’ needs and aiding the patient/family to recover and heal (restore trust, hope and confidence). The interaction / response must not cause further harm. Stress or suffering, and the content of the interaction, for example a letter, should not have been compromised, as often occurs, by competing priorities of the organisation to the detriment of the patient/family. Thus, these blogs will look at: The processes that occur after an incident of harm (Duty of Candour, incident investigation, complaint, inquest) with the aforementioned focus. The care the patient and family need and the obligation (that ought to exist) to meet that need. Processes that are core to the package of ‘care’ to be provided to the harmed or bereaved and to be delivered by skilled and supported ‘care providers’. The blog series will seek to show that meaningful patient engagement in all of these processes is crucial for restoring trust, confidence and hope; therefore, aiding healing of all groups in the aftermath of harm. “It is important to respect and support the active involvement of patients and their families in seeking explanations and deciding how best they can be helped. Indeed at a time which is often characterised by a breakdown of trust between clinician and patient, the principle of actively involving patients and families becomes even more important.” Vincent and Coulter, 2002[3] It will also consider the additional care and support needs that might need to be met alongside these processes in a holistic package of care, such as peer support, specialist medical harm psychological support and good quality specialist advice and advocacy. It will describe what is currently available and what more is needed if healthcare is to provide adequate care for those affected by medical error in order to give them the best chance of recovery. Alongside this, the needs of the staff involved will also be considered. We welcome opinion and comments from patients, relatives, staff, researchers and patient safety experts on what should be considered when designing three harmed patient care pathways: for patients, families and staff. What is the right approach? What actions should be taken? How can these actions be implemented? What more needs to be done? Join in the discussion and give us your feedback so we can inform the work to design a harmed patient care pathway that, when implemented, will reduce the extra suffering currently (and avoidably) experienced by so many. Comment on this blog below, email us your feedback or start a conversation in the Community. References 1. Leilani Schweitzer. Transparency, compassion, and truth in medical errors. TEDxUniversityofNevada. 12 Feb 2013. 2. Bell SK, Etchegaray JM, Gaufberg E, et al. A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families. J Comm J Qual Patient Saf 2018;44(7):424-435. 3. Vincent CA, Coulter A. Patient safety: what about the patient? BMJ Qual Saf 2002;11(1):76-80. 4. Anderson-Wallace M, Shale S. Restoring trust: What is ‘quality’ in the aftermath of healthcare harm? Clin Risk 2014;20(1-2):16-18. 5. Wu AW. Medical error: the second victim: The doctor who makes the mistake needs help too. BMJ 2000;320(7237):726-727. 6. Shorrock S. The real second victims. Humanistic Systems website. 7. Clarkson M, Haskell H, Hemmelgarn C, Skolnik PJ. Editorial: Abandon the term “second victim”. BMJ 2019; 364:l1233. 8. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care 2009;18(5):325-330. 9. Second victim support for managers website. Yorkshire Quality and Safety Research Group and the Improvement Academy. 10. Trew M, Nettleton S, Flemons W. Harm to Healing – Partnering with Patients Who Have Been Harmed. Canadian Patient Safety Institute 2012. 11. Vincent C. Patient Safety. Second Edition. BMJ Books 2010.

Key findings 1. We are in a public health crisis, but only our community connects it to underlying deficiencies with the healthcare system. The coronavirus pandemic is top of mind for everyone we polled, including those in our community and the general public. However, not surprisingly, our community has a much broader concern over access and availability of healthcare, at more than double than the general public. This is chiefly due to misgivings our community feels about how well the healthcare system serves patients on a range of areas, from safety to putting patients first to being generally accessible. 2. Bringing healthcare workers into patient safety meets the moment and expands the coalition Due to the pandemic, healthcare worker health has become a top concern. Now is the time to bring medical professionals into the patient safety conversation as they rank as one of the most important groups of people we should be caring for today. Utilizing this moment to bring them into the conversation as part of patient safety can help mobilize the public and our community in ways we haven’t seen previously 3. The community strives for preventing all medical error, not just that which leads to harm Even though medical error is a pervasive issue, there is optimism that error can be prevented and that we can make that change happen. Among our community 80% believe all or three-quarters of medical error can be prevented. 4. The patient safety movement needs to carry forth a message to the broader public for why incentivizing best practices leads to better outcomes and system-wide improvements in safety Our community believes providing incentives to organizations and people that practice good patient safety (51%) is more impactful than holding organizations accountable through punitive action (41%). This is flipped from the general public, where a majority say the better way of reducing harm is holding individual organization and people accountable.

It's been a busy few months to say the least. Preparing for the pandemic, sourcing correct personal protective equipment (PPE), redeploying staff, acquiring new staff, making ventilators, redesigning how we work around the constraints, writing new policies, new guidance, surge plans, and then the complex part… caring for patients. If I am honest, when this all started it felt exciting. Adrenaline was high, motivation was high, we felt somewhat ready. There was a sense of real comradeship. It felt like we were all working for one purpose; to safely care for any patient that presented to us in hospital. We were a little behind London by about 2–3 weeks, so we could watch from afar on how they were coping, what they were seeing and adapting our plans as they changed theirs. Communication through the ITU networks was crucial. Clinical work has been difficult at times. The initial confusion on what the right PPE to wear for each area added to the stress of hearing that our colleagues in other places were dying through lack of PPE. The early days for me were emotionally draining. However, this new way of dressing and level of precaution is now a way of life for us. I have come to terms that I am working in a high-risk area and I may become unwell, but following guidance and being fastidious with donning and doffing helps with ‘controlling’ my anxieties in catching the virus. Some parts of the hospital remained quiet. Staff had been redeployed, elective surgery cancelled and the flow of patients in the emergency department (ED) almost stopped. I remember walking through ED and thinking: where are the people who have had strokes? Have people stopped having heart attacks? Are perforated bowels not happening anymore? The corridor in ED is usually full. Ambulances queuing up outside, but for a good few weeks the ambulance bays were deserted. The news says over and over again "we must not overwhelm the NHS". I always have a chuckle to myself as the NHS has been overwhelmed for years, and each year it gets more overwhelmed but little is done to prevent winter surges, although it's not just winter. The surge is like a huge tidal wave that we almost meet the crest of, but never get there, and emerge out the other side. I sit in the early morning ITU meeting. We discuss any problems overnight, clinical issues, staffing and beds. We have seen a steady decline in the number of ITU patients with COVID over the last week or so. The number of beds free for COVID patients were plentiful. We have enough ventilators and staff for them. This is encouraging news. I take a sigh, thinking we may have overcome the peak. In the next breath, the consultant states that we don’t have any non COVID ITU beds. We have already spread over four different areas and are utilising over 50 staff to man these beds (usually we have 25 staff). So that’s where the perforated bowels, heart attacks and strokes are. The patients we are caring for had stayed at home too long. So long, that they now have poorer outcomes and complications from their initial complaint. These patients are sick. Some of the nurses who are looking after them are redeployed from other areas; these nurses have ITU experience, but have moved to other roles within the hospital. This wasn’t what they had signed up for. They were signed up for the surge of COVID positive patients. I’m not sure how they feel about this. As the hospital is ‘quiet’ and surgical beds are left empty, there is a mention of starting some elective surgery. This would be great. It would improve patient outcomes, patients wouldn’t have to wait too long, so long that they might die as a consequence. However, we don’t have the capacity. We have no high dependency/ITU beds or nurses to recover them. We would also have to give back the nurses and the doctors we have borrowed from the surgical wards and outpatients to staff ‘work as normal’, depleting our staff numbers further. Add to the fact that lockdown has been lifted ever so slightly, the public are confused, I’m confused. With confusion will come complacency, with complacency will come transmission of the virus and we will end up with a second peak. If we end up with a second peak on top of an already stretched ITU and reduced staffing due to the secondary impact on non COVID care, the NHS will be overwhelmed. This time we will topple off that tidal wave. It’s a viscious cycle that I’m not sure how we can reverse. My plea, however, is to ensure we transition out of this weird world we have found ourselves in together. We usually look for guidance from NHS England/Improvement, but no one knows how best to do this. The people who will figure this out is you. If your Trust is doing something that is working to get out of this difficult situation, please tell others. We are all riding the same storm but in different boats. I would say that I am looking forward to ‘business as usual’ – but I can’t bare that expression. Now would be a great time to redesign our services to meet demand, to involve patients and families in the redesign – to suit their needs. We have closer relationships now with community care, social care and primary care, we have an engaged public all wanting to play their part. Surely now is the time we can plan for what the future could look like together? The Government has announced that Ministers are to set up a ‘dedicated team’ to aid NHS recovery. We need to ensure that patient and staff safety is a core purpose of that team’s remit and the redesign of health and social care. Would you be interested in being on our panel for our next Patient Safety Learning webinar on transitioning into the new normal? If so, please leave a comment below.

The SPSP website has many tools, resources and useful links, including: Patient Safety Climate Tool Patient Safety Climate Tool Guidance SPSP-Mental Health Measurement Plan

View recording of the webinar To read more about our top highlights and takeaways from the webinar, and how we're using your questions and concerns to shape our work in non COVID-19 care and patient and staff safety, please see our blog. We'd love to hear more of your views and questions to help inform Patient Safety Learning's future webinars. Please share ideas for topics in our Community thread.

The letter outlines five important challenges that will need to be addressed by leaders in government and the health and care system: How and when will appropriate infection prevention and control measures be available for all settings delivering care, and what impact will these have on capacity to reopen? How will the system understand the full extent of unmet need? How will the public’s fear of using NHS and social care services be reduced? What is the strategy for looking after and growing the workforce? Can the system improve as it recovers?

The Committee identified the following health-related objectives of the lockdown withdrawal strategy: 1. Reduce spread of the COVID-19 virus. 2. Minimise loss of healthcare professionals and maximise their safety and availability to continue the work. 3. Increase case management capacity in existing hospitals and new hospitals. 4. Increase testing to eliminate community spread. 5. Ensure access to normal healthcare requirements of the population. 6. Maintain normal healthcare capacity during the coronavirus period. 7. Maintain public health initiatives (vaccinations, food/nutrition of children and pregnant/feeding mothers.