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What defines a hostile environment? I would suggest looking at these images. They are dynamic, isolated, extreme, stressful, high stakes, fragmented, unpredictable with goal conflicts and information challenges.

What does this have to do with healthcare?

Well firstly, I believe we work in a hostile environment. Our work is dynamic, unpredictable, stressful, with fragmented information, high stakes, goal conflicts and isolated. Taking responsibility for critical decisions regarding safety can be incredibly isolating.

Secondly, there are goal conflicts. There is always a balance between productivity, efficiency and safety and it can be a difficult line to tread when there are bed pressures, time targets, training to deliver and experiences to gain.

Thirdly, the stakes are high. The consequences of medical error have far reaching impact on our patients, our personnel, our patient’s relatives and our organisations.

The stakes are high for our personnel as medical error can mean investigation by a governing body, loss of licence to practice, charges of manslaughter and loss of sanity.

A retrospective study of prosecutions for manslaughter due to medical error found two doctors prosecuted from 1970-79, two doctors from 1980-89, 17 doctors from 1990-99. Of these, 10 were convicted. Physician health experts estimate that 250 doctors per year commit suicide in the US, a rate that is two times that of the general population and this risk increased three fold following a medical error.

The stakes are high for patient’s relatives. Harvard University performed a case control study to look at the psychological impact of medical error upon the relatives of victims, they found that these families suffer from enduring, emotional duress that diminishes their ability to enjoy life and are at increased risk of PTSD with 37.5% of those studied reporting symptoms of PTSD.

The stakes are high for our organisations with the continued cost of care, additional costs of remuneration, potential litigation and loss of reputation.

Interestingly, before going to work in a war zone, professionals such as journalists get training in hostile environment awareness. They are taught to use the “safety compass”- assess, anticipate and mitigate threats within the environment, prepare and plan for the emergencies you may encounter. This could be one way of viewing our WHO team brief – we assess the threats to patient safety, anticipate problems (for example: blood loss) and plan for emergencies by checking our emergency equipment and delegating roles for CPR.

The first step on the road to safety is to recognise we are walking through a hostile environment.

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