Burnout and patient safety

ALL members of the healthcare team can experience burnout. This commonly manifests as a feeling of being overwhelmed by the demands of the role, exhaustion and an inability to engage effectively with others. The link between reduced wellbeing of clinicians and negative effects on patient safety and quality of care is of particular interest to MDDUS. There is well-established evidence of a causal relationship within secondary care settings but a recent article published in the British Journal of General Practice* investigated the phenomenon within primary care.

The study examined whether factors known to contribute to burnout and wellbeing could be associated with patient safety (measured by near misses) in general practice. These factors include increased paperwork and patient demand, and a lack of support.

Further research will be required to define the extent of the causal links, however the findings suggest (similar to secondary care) that a high number of hours spent on administrative work was associated with poorer wellbeing, which in turn was associated with a higher likelihood of being involved in a near miss. The study also found that a lack of adequate support within practices, alongside high patient demand, was associated with higher levels of burnout, exhaustion and lower perceptions of safety. Whether these factors lead to burnout or vice versa, the fact that patient safety can be impacted is legitimate.

In analysing MDDUS medico-legal cases, we find that the most common causes of claims are associated with missed/delayed diagnosis or alleged failures in clinical treatment. Within these categories, common themes include:

• misfiling a result
• failing to follow-up a patient
• forgetting to complete a referral
• failing to document a consultation adequately
• missing an alert from a clinical system
• selecting the wrong item from a drop-down list or ticking/failing to tick a box as part of a process.

These are also common trends within incidents reported as near misses. This is understandable when you consider the ‘symptoms’ of burnout or reduced wellbeing:

• impaired cognitive function
• decreased recall and attention to detail
• greater susceptibility to alert fatigue and information overload
• poorer interactions with patients and colleagues
• able to cope only with shorter, more specific encounters
• less able to notice changes to a patient’s condition
• less likely to be able to provide help or support to colleagues
• increased negative emotions towards patients/colleagues, requiring increased levels of self-management/control
• poor communication with others (patients and colleagues, verbally and in writing) leading to loss of situational awareness.

Clinicians are expected to (and learn to) deal with significant levels of demand, exhaustion and stress throughout their career. However, to avoid future increases in unintentional patient harm (and the impact on clinicians), underlying conditions of work within both primary and secondary care must be examined closely.

Discussions around this issue often focus on the financial costs to the NHS when clinicians leave practice as a result of burnout. But real changes within systems and processes could mitigate the risks of burnout.

ACTION POINTS

• Consider whether you are experiencing symptoms related to burnout or exhaustion
• Identify a colleague or other with whom you can share your concerns and who can offer support or coaching
• Clinical leads should consult with teams about whether they feel supported and identify ways in which to improve this
• Incident reporting systems should be examined to understand whether they are robust enough to provide early warning signals of increased clinical risk. Evidence indicates that the number of near misses and minor incidents should be around 70 per cent of all incidents reported
• Use of more tangible measures of patient safety is helpful as there is evidence that clinicians experiencing burnout may be more likely to assess patient safety as lower due to their emotional state
• Leads should also review good practice in improving and (where possible) automating workflow within the service, ensuring better system safety netting and a reduced administrative burdens on clinicians.
• Investigate and consider implementing the many good examples of organisations refining or simplifying existing processes, and upskilling other members of the healthcare team to share the burden with an eye on risk.

Liz Price is senior risk adviser at MDDUS

* Hall L H, et al. (2019) Association of GP wellbeing and burnout with patient safety in UK primary care: a cross sectional survey. BJGP