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Risk management
Anxiety as a barrier to risk management
  1. J Firth-Cozens
  1. Correspondence to:
 Professor J Firth-Cozens, London Deanery, 20 Guilford Street, London WC1N 1DZ, UK;

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Leaders need to recognise that anxiety is an inevitable part of caring for patients and that, without the building of trust, it may affect risk management by reducing the reporting of error.

The paper by Kuhn and Youngberg1 in this issue of QSHC takes an historical approach to the evolution of risk management, following it from past failures into the path for its future success. The essence of the change will occur with the primary goal of risk management moving from the protection of the financial concerns of the organisation to the protection of its patients in terms of improved safety and quality of care. For decades risk management has sat uneasily beside quality systems, and it is only with the integration of these systems into one which has good patient care as its ultimate goal—clinical governance in the UK—that there is the possibility of success.

Nevertheless, while the structural integration of quality systems may be relatively straightforward, the psychological integration of the concepts of “quality = good” and “error = bad” will take much longer to address. It is this splitting off of painful anxiety about real or potential errors—the fear, guilt and shame that it involves2,3—which lays in the uncomfortable unconscious of health care and which makes the task of risk management so difficult. Many years ago Isobel Menzies-Lyth conducted her seminal exploration of the ways in which healthcare organisations and professions structure themselves and their procedures in order to protect themselves from the anxiety associated with caring for distressed, diseased, and dying patients.4 Her work is embedded primarily in the provision of good care; however, accepting that error is not rare but a strong possibility for all individuals and that such error can lead to the very distress, disease, and death that we strive to relieve, cure or avoid may make the anxiety she explores potentially unbearable. Our new risk management depends upon the open discussion of error but, as we saw in Bristol, defences against anxiety are likely to create new barriers to seeing and accepting this error.

I would suggest that it is these barriers against anxiety which have until now stopped risk management being successfully integrated into the whole system of improving patient care: risk managers have traditionally been kept physically separate from other systems, seen as something of a joke, a burden clinicians sometimes have to bear, interested only in the tedious. These are the defences of a staff hard pressed, often under-resourced and, not surprisingly, unwilling to get involved with the anxiety provoking idea that error is an ordinary everyday event.

“It is the splitting off of painful anxiety about real or potential errors . . . which makes the task of risk management so difficult”

The addressing of near misses is seen as an essential part of the new risk management5 and should make the discussion of error less difficult by focusing on potential rather than actual problems. However, there is also the argument that people adapt their behaviour more determinedly when a failure or disaster has happened to them rather than to someone else. For example, those in the town next to one hit by hurricane Hugo did little to protect their homes from future hurricanes, while those in the damaged town built strong defences for the future.6,7 A focus on near misses seems intuitively as useful in health care as it was in air travel, but we simply do not know the extent to which this will be offset by a lack of salience to overstretched staff. This, along with so many of the fundamental questions about patient safety, shows the need for a well funded and carefully considered programme of research for this crucial area.

The authors focus upon leadership as one way towards the new culture where error will be discussed and addressed within the whole system rather than by individual staff members. As they suggest, leaders need to attend not just to the financial business case but also to the moral one if they are to succeed in providing better patient safety. This moral case will include leaders taking on issues of trust—for example, that patients will be told the truth, that staff will be treated justly, and systems will be tackled to change what went wrong. Trust will be engendered through clarity about accountability, through honesty, and by consistency on the part of the leaders concerned.8 Finally, these leaders need to be aware of the anxiety faced by staff and by themselves in the provision of health care. It is so easy for a Chief Executive to avoid seeing what clinicians and patients have to face daily in their organisation, but it will not help trust to develop if they do.

Anxiety is thus a fundamental part of health care; not something we can change but something to be aware of so that the defences we build against it do not end up making the risk management of the future as unsuccessful as that of the past.

Leaders need to recognise that anxiety is an inevitable part of caring for patients and that, without the building of trust, it may affect risk management by reducing the reporting of error.


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