36
ADMINISTRATION SERIES: MEDICAL ERROR Jay Green Dr. Lisa Campfens March 11, 2010
ADMINISTRATION SERIES: MEDICAL ERROR
Jay Green
Dr. Lisa Campfens
March 11, 2010
Outline
Introductory info Error Small group cases AHS guidelines Disclosure Small group cases Documentation/Law Case discussion
10 min
10 min
30 min
10 min
20 min
5 min
Objectives
Understand models of error Learn the steps in management of a
severe adverse event Understand the Alberta Health Services
Disclosure of Harm Policy Understand what types of events require
disclosure Learn how and what to disclose when
error happens
Medical error stats
2004 HQCA Alberta Patient Safety Survey2004 HQCA Alberta Patient Safety Survey
Results N=1512 7.5% AE rate, higher in teaching hospitals
37% thought to be highly preventable 5% permanent disability, 16% death Medication safety, surgery top 2 areas
Adverse EventHarmClose CallMedical Error
Canadian Disclosure Guidelines. Canadian Disclosure Guidelines. Canadian Patient Safety InstituteCanadian Patient Safety Institute
Guiding Principles
Autonomy
Patie
nt Cen
tere
d Car
eHonesty
Tran
spar
ency
Trust
Human Error
Reason. Human error: models and management. Reason. Human error: models and management. BMJBMJ 2000;320:768-70 2000;320:768-70
Error prevention?
Small group cases #1
10 minutes Cases 1 & 2
Management of Serious Adverse Events
iweb.calgaryhealthregion.ca/qshi
Immediate management: RESPOND
Continuing management: ACE
RESPONDResuscitate patient
Ensure environment safe
Secure equipment
Protect other patients
Offer initial support
Notify
Disclosure (Acknowledgment)
SERIOUS* (POTENTIAL) ADVERSE EVENT†
SAFETY LEARNING REPORT
DISCLOSURE TO PATIENT & FAMILY
SAFETY ANALYSIS
ADMINISTRATIVE REVIEW
INITIAL ASSESSMENT
IMMEDIATE MANAGEMENT
ONGOING SUPPORT FOR
HEALTHCARE PROVIDERS
ASSIGN A PATIENT ADVOCATE
* Serious – Fatal or Severe (loss of limb or organ function or resuscitation required to sustain life)
or substantial risk thereof (close call)†
ONGOING SUPPORT FOR
PATIENT & FAMILY
ADVOCATE COMMUNICATE EVALUATE
Initial TimelineClinical Safety Evaluation
INFORMING
CONTINUING MANAGEMENT
Just & Trusting Culture
Safety Learning Report
Disclosure
Disclosure = ?
Disclosure: Underlying Principles
Hickson, 1992; Beckman, 1994; Vincent, 1994; Kraman, 1999; Gallagher, 2003
What does it mean?
Why don’t we want to do it?
When do we do it?Cl
ose
call
No
harm
Min
imal
har
m
Mod
erat
e ha
rm
Seve
re h
arm
Fata
l har
m
Required DisclosureDiscretionary Disclosure
Who does it?
How do we do it?
Immediate Acknowledgment Initial Disclosure Follow-up Disclosure Final Disclosure
Apology Listen Empathize Offer to explain
AHS Procedures for Disclosing Harm to Patients
Acknowledge
Apology
“Apology is not an ethical right, but a therapeutic necessity” – Lucian Leape
Small group cases #2
10-15 minutes Cases 3, 4 & 5
“Confronted by an empathetic and apologetic physician, patients and families can be astonishingly forgiving.”
“Only then is it appropriate to approach the mistake with a problem solving focus”
Disclosure Tips
Set the tone Timeliness Privacy Setting Body language Be in control, but not controlling Simple, slow Interactive Avoid speculation Describe next steps
AHS Procedures for Disclosing Harm to Patients
Canadian Medical Protective Association Information Sheet, March 2005Canadian Medical Protective Association Information Sheet, March 2005
Case discussion
Take-home points
Adverse events are common System approach to error RESPOND to serious adverse events Disclosure is mandatory when patients
have suffered any level of harm Disclosure is often a multi-step process
RESPONDResuscitate patient
Ensure environment safe
Secure equipment
Protect other patients
Offer initial support
Notify
Disclosure (Acknowledgment)
SERIOUS* (POTENTIAL) ADVERSE EVENT†
SAFETY LEARNING REPORT
DISCLOSURE TO PATIENT & FAMILY
SAFETY ANALYSIS
ADMINISTRATIVE REVIEW
INITIAL ASSESSMENT
IMMEDIATE MANAGEMENT
ONGOING SUPPORT FOR
HEALTHCARE PROVIDERS
ASSIGN A PATIENT ADVOCATE
* Serious – Fatal or Severe (loss of limb or organ function or resuscitation required to sustain life)
or substantial risk thereof (close call)†
ONGOING SUPPORT FOR
PATIENT & FAMILY
ADVOCATE COMMUNICATE EVALUATE
Initial TimelineClinical Safety Evaluation
INFORMING
CONTINUING MANAGEMENT
The END
