If Zero Harm Only Means Physical Harm, We are STILL HARMING PATIENTS.

First, do no harm. Everyone in healthcare (and outside healthcare) has likely heard those four words before. It helps set our priorities as caregivers and could likely be the forerunner to Zero Harm. 

The Zero Harm approach to healthcare likely has roots in the safety culture of other high-risk industries, specifically aviation. The Institute for Healthcare Improvement (IHI) notes the goal of Zero Harm is "to prevent all patients from experiencing harm while receiving healthcare.". The IHI explicitly points to the importance of having a safety culture where patient safety is prioritized. Many organizations, including the World Health Organization (WHO), support Zero Harm. Many articles and books have been written about Zero Harm. Interestingly, the name Zero Harm and the tenants behind it are not universally accepted in healthcare. There are knowledgeable people who have made compelling arguments on both sides.  While I won’t get into the full details on both sides of the argument in this discussion, I am of the belief that Zero Harm is achievable and is an imperative for us in healthcare. Regardless of opinions about the name and tenants of Zero Harm, there is a nearly universal agreement that healthcare must minimize the risk of harm to patients and continuously work to improve patient safety…thankfully!

Before discussing expanding our definition of the word harm, I want to be very clear.

In healthcare, safety is our number one priority. Period.

Unequivocally. 

Now that we have established that safety is our number one priority think about the word harm.

What automatically comes to mind?

You wouldn't be faulted for thinking about harm relative to physical harm. Stories likely come to mind of the horrific experiences of physical harm shown in news reports. Some people will recall when they or someone they care about experienced a medical error. It could be a medication error, surgical error, diagnostic error, or any number of events classified as "harm." If you were to venture out to The Joint Commission website, there are resources focused on helping hospitals get to Zero Harm, all focused on physical harm. However, if we are only thinking about harm within the context and confines of physical harm, we are neglecting a vital component of what should be a comprehensive harm reduction strategy…emotional harm. 

Emotional harm in healthcare refers to the psychological or emotional suffering experienced by a patient and/or their family due to their interactions with caregivers or the healthcare system. The genesis of this type of harm can occur from many factors, but one of the biggest is a lack of compassion. And before you think, "this is just soft skills, "let me assure you it is not. Research shows emotional harm leads to negative outcomes for patients. Isn't improving outcomes part of what we do in caring for others?

For example, patients who reported experiencing emotional harm during their hospital stay were more likely to have adverse health outcomes, including longer hospital stays and higher readmission rates…things that healthcare organizations are laser-focused on improving!

Indeed, more than one study is needed to make something evidence-based. Thankfully, many other peer-reviewed studies show the negative impacts of emotional harm on healing, immune health, erosion of trust, and willingness to seek care. 

A failure to include emotional harm in the discussions about Zero Harm is not only failing our patients but also contributing to negative outcomes for those we are entrusted to care for. And please allow me to reiterate what I noted before; I am not calling for it to be a discussion of Zero Harm for physical harm or emotional harm.

I am raising the alarm bells and screaming from the mountain tops that it must be a commitment to Zero Harm for physical harm and emotional harm. Not only is eliminating emotional harm as part of a comprehensive strategy for Zero Harm an ethical and moral obligation in healthcare, it is evidence-based medicine!  Further, a lack of compassion and emotional harm in healthcare pose a serious patient-safety risk.  The evidence is clear, we must empower our teams and create systems that eliminate emotional harm.  Anything less that Zero Harm, both emotional and physical harm is unacceptable. 

Think about your last interaction with a patient and/or family. Did your interaction result in emotional harm? 

Aside from system processes, can you guess what the antidote to emotional harm is…compassion!  Compassion as part of an integrated patient-centered approach to care! So, the next time you hear or think about the words of the ancient Greek physician Hippocrates, "First, do no harm," be sure to include emotional harm with physical harm!

And…here are some references to verify and validate the impact of emotional harm!

Epstein RM, Street Jr RL. The values and value of patient-centered care. Annals of Family Medicine. 2011 Jul 1;9(2):100-3. doi: 10.1370/afm.1239. PMID: 21403143.

Gao X, Xu R, Zhai J, Chen G, Chen X. Exploring the relationship between emotional harm, social support and quality of life among Chinese patients with thyroid cancer. Journal of Psychosocial Oncology. 2020 Nov 19;39(1):19-30. doi: 10.1080/07347332.2020.1832627. PMID: 33190605.

Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians' empathy and clinical outcomes for diabetic patients. Academic Medicine. 2011 Sep 1;86(9):359-64. doi: 10.1097/ACM.0b013e318226b2a5. PMID: 21785307.

Hsu MY, Liao YC, Chen LM, Wu IW, Huang CY, Wu MS, Hung KY. The association between patient-centered care and outcomes in a comprehensive cancer center. Journal of Nursing Scholarship. 2018 May;50(3):271-9. doi: 10.1111/jnu.12382. PMID: 29148190.

Ratanawongsa N, Karter AJ, Parker MM, Lyles CR, Heisler M, Moffet HH, Adler NE, Warton EM, Schillinger D. Communication and medication refill adherence: the Diabetes Study of Northern California. JAMA Internal Medicine. 2013 Apr 8;173(7):210-8. doi: 10.1001/jamainternmed.2013.1216. PMID: 23440143.

Street Jr RL, Slee C, Kalauokalani DK, Dean DE, Tancredi DJ, Kravitz RL. Improving patient involvement in care: effects of a decision aid for women with breast cancer. Patient Education and Counseling. 2013 Sep 1;91(3):372-7. doi: 10.1016/j.pec.2013.02.013. PMID: 23522868.

Williams J, Stickley T. Empathy and nurse education. Nurse Education Today. 2010 May 1;30(4):323-7. doi: 10.1016/j.nedt.2009.10.016. PMID: 20031286.