Document resource
Background The risk of compromising patient safety and burden of error for all healthcare professionals is well documented (Best. The burden of medication error. Queen’s Institute of Community Nursing. 2022 Sept 21. [internet]). This may be even more complex when caring for patients and significant others who are already facing transition and loss at the end of life.Aims The authors worked together in a clinical scenario – in which both were deeply affected; one as the individual responsible for an error and the other for the subsequent investigation. An intention was deliberately set during the process: both to adopt a feelings-based and vulnerable approach to reviewing the impact of making errors within hospice care, and to share this personal journey with each other and colleagues, in order to support resilience and nurture a culture of openness.Methods Presentations were made at our multi-professional clinical update series. This included using a structured reflective model, to give insight into the feelings and experiences of both parties, and encourage open discussion (Greenaway. Reflection toolkit: Reflecting on experience: The four F’s of active reviewing. University of Edinburgh. 2024 [internet]). It also included sharing a personal toolkit, which recognises the impact of our emotional systems and core values, whilst not diminishing the level of responsibility and accountability that professionals must uphold.Results Initial responses to this work have included ‘ This is the most powerfully honest presentation I have ever witnessed’ (hospice doctor) and ‘I wish I had heard this before I made my error, I may have felt less alone and terrified’ (hospice registered nurse). Completing this has been hugely instrumental in allowing the authors to find self – forgiveness, deeper working connections and psychological safety.Conclusion Further work will include the production of a recording of the presentation, a leaflet, and prompt card. These resources will safeguard peer and senior support and self-care that compassionately recognises the impact of making errors, including (following feedback) considering how neurodiverse colleagues may be impacted. This will be shared at the conference.