Transcript Medical Errors: Real or Perceived: Patient & Physician must

Medical Errors and
Adverse Events:
Real or Perceived?
Physicians and Patients
Must Collaborate
Irvin B. Krukenkamp, M.D., FACS, FAHA
&
Mary Ellen Mannix, Founder PULSE of PA
Key Issues: Healthcare Team & Communication
For the safest and best communication practices in healthcare:
1.
The public MUST actively engage their collective
patient voice.
2.
Healthcare providers MUST actively engage as a
singular voice within a compassionate community.
3.
Doctors & patients MUST utilize a collaborative voice
in hospitals, medical schools and community-based
organizations.
4.
Communication MUST be unfettered by the fears of
litigation or retaliation.
By Mary Ellen Mannix, Founder
PULSE of PA
www.pulseofpa.org
[email protected]
610.299.0478
The Doctor’s Role
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Answer finder
Healer
Life Saver
Empathizer
Teacher
Meaning Giver
 Do you have an Informed Patient?
of PA
 Social worker: “He is on bypass now.”
 Alarmed parent: “What’s wrong?”
 Social worker: “Everything’s fine. This is part of the
procedure.”
of PA
“What happened?”
“Economists assume people focus solely on outcomes.
People want to know that they had their say – that
their point of view was considered even if it was
rejected.”
~Kim &Mauborgne, “Fair Process: Managing in the
Knowledge Economy”, Harvard Business Review, 2003.
of PA
“You trusted us.”
Surgeon not available
- after initial surgery
- after respiratory led cardiac arrest
- or after final surgery.
Surgeon/Cardiac Center director & other administrators escorted
by federal marshalls off hospital grounds 18 months later under
FDA investigation.
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Compass of Shame
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 “Conflict is taken away, given away,
melts away, or is made invisible.”
– Nils Christie, 1977. “Conflict As Property.”
The Attorney’s Role:
 Willing Confidant
 Empathizer
 Life Saver
 Answer Finder
 Meaning Giver
of PA
Social Discipline Window
“Snitches get stitches.”
Medical providers are aware of the behavior of their
peers.
A best practices tool would be the avenue through which
they can express concerns and information in a
supportive, fair process environment. They need to be
as much of the process as the patients.
of PA
Healing the Scars
For participants in
challenging behaviors:
 What happened?
 What were you thinking at
the time?
 What have you thought about
since?
 Who has been affected by the
care outcome? In what way?
 What do you think needs to
be done to foster healing?
For living with challenging
outcomes:
 What did you think when you
realized what happened?
 What impact has this care or
care outcome had on you and
others?
 What has been the hardest
thing for you?
 What do you think needs to
happen to foster healing?
“Peace is not something you wish for; its something you make,
something you do, something you are, something you give away.” Robert Fulghum
James
A Challenging Case
in the Fight for
Patient Safety
By Irvin B. Krukenkamp, M.D.
http://www.doctork.org
e-mail: [email protected]
© 2007 - All Rights Reserved
Breakdown in
Patient Safety and
Quality of Care
Courage and strength of character are required
to advocate for Patient Safety despite the
myriad of conflicts of interest.
Key Issues - Children’s Heart Surgery Program
1. Low # of cases per
year
2. Itinerant surgeon
3. Head not a surgeon
4. Conflicts of interest
Baby Doe Dies!
Sentinel Event and Other Near Misses
Confidential Letter to the CEO
 Moral, Ethical, Professional Duty
 Issues of Patient Safety & Quality of Care
 Fundamental Conflicts of Interest
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Head of Program was Baby’s Doctor
Head of Program Directed its QA
Head of Program was Head of Hospital QA
Head of Program was Hospital CMO
Head of Program Reported to the CEO
CEO to Lead Change
and Protect
Patient Safety
For example - cohort all surgeries
into one week per month.
On the Defensive..
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Record of Accomplishments
Protect Career
Negotiate
Avoid Media
DOH Review
Program closed - 36 citations for violations of
patient safety and public health code.
Do It Again?
YES - Wouldn’t You?
A Challenging Case
in the Fight for
Patient Safety
By Irvin B. Krukenkamp, M.D.
http://www.doctork.org
e-mail: [email protected]
© 2007 - All Rights Reserved
Key Issues: Healthcare Team & Communication
For the safest and best communication practices in healthcare:
1.
The public MUST actively engage their collective
patient voice.
2.
Healthcare providers MUST actively engage as a
singular voice within a compassionate community.
3.
Doctors & patients MUST utilize a collaborative voice
in hospitals, medical schools and community-based
organizations.
4.
Communication MUST be unfettered by the fears of
litigation or retaliation.
Medical Errors and
Adverse Events:
Real or Perceived?
Physicians and Patients
Must Collaborate
Thank you for your attention!
Questions??