Hospitals have made significant strides to reduce or eliminate physical harm to patients since the landmark 1999 Institute of Medicine Report "To Err is Human." In a new paper published in BMJ, patient care leaders at Beth Israel Deaconess Medical Center (BIDMC) say hospitals must now devote similar attention to eliminating emotional harms that damage a patient's dignity and can be caused by a failure to demonstrate adequate respect for the patient as a person.
"Emotional harms can erode trust, leave patients feeling violated and damage patient-provider relationships," writes lead author Lauge Sokol-Hessner, MD, a clinician in the BIDMC Hospital Medicine program and the Associate Director of Inpatient Quality. "Such injuries can be severe and long-lasting, with adverse effects on physical health. Failure to acknowledge and systematically address these harms ensures that they continue."
"For these emotional harms, we are where we were with patient safety before 1999: we know they occur but lacking a systemic approach to capture, categorize or assess them, we struggle to understand root causes and prevent future events," writes Sokol-Hessner. "We do not have reliable estimates of how often such harms occur, but some evidence suggests that they may be more prevalent than physical harms."
Previous studies have shown patients often emphasize emotional rather than physical harm in discussing adverse events. Such harms may include a failure to conduct a sensitive conversation in a suitably private setting; misplacing or losing sentimental objects; or "never events" such as sending a funeral home the wrong body after a patient passes away.
In their BMJ paper, the authors highlight the work BIDMC has done to promote dignity and respect in patient care. In 2008, the medical center launched an effort to publicly report a variety of patient safety issues as part of its effort to reduce and eliminate physical harms. Building on this work, BIDMC also made a significant commitment to defining the loss of dignity and respect as a preventable harm and taking active steps to prevent them.
BIDMC convened a multidisciplinary "Respect and Dignity" Workgroup -- with representatives from across the medical center, including health care quality, patient safety, ethics, social work, interpreter services, patient relations, and the Patient Family Advisory Council.
The BIDMC team set out to define emotional harm as something that affects a patient's dignity by the failure to demonstrate adequate respect for the patient as a person. That definition acknowledges that not all emotional harm is a consequence of a human failure to demonstrate respect. For example, a patient may be embarrassed by a requiring a post-surgical colostomy bag or harmed by the lack of privacy because a hospital does not have enough private rooms.
BIDMC then made a commitment to identifying and tracking emotional harms using the same databases used to document physical harms.
"Ensuring that our profession does not cause preventable harm to our patients requires that we address emotional harms with the same rigor we have applied to physical harms," adds Kenneth E. Sands, MD, MPH, senior author and BIDMC's Senior Vice President of Health Care Quality and Chief Quality Officer at the Silverman Institute for Health Care Quality and Safety.
"A reliable culture of respect for patients almost certainly requires a culture of respect among organizational leaders and staff," adds co-author Patricia Folcarelli, RN, PhD, Senior Director of Patient Safety at BIDMC.
The authors stress that health care facilities must also identify and acknowledge personal and systemic factors that may be associated with emotional harms, such as a lack of training, a stressful work environment or faulty systems of care.
Reported cases of loss of respect need to be reviewed with a root cause analysis similar to ones used for physical harm because "our early experience with emotional harms is that they are often the result of multiple failures." These failures might involve not only the provider's skills and attitude but also the work environment, information technology systems and care team communication.
"There are many challenges in this work, including establishing operational definitions of 'respect' across culturally diverse patient populations," Sands notes. "Overcoming these challenges should become our mission as we fulfill our fundamental ethical responsibility to 'do no harm.'"
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