Transcript Eight Steps to Respond To Sentinel Events and Critical Incidents

Reclaiming your patient’s trust
after an unexpected outcome
The Medical City Good Hospital
Practice Training Series 2009
OUTLINE of presentation
A.Eight steps in responding to unexpected
outcomes
B.The importance of disclosure
C.Disclosure policies – who, when, what, how
D.What open disclosure means to our patients
and staff
INTRODUCTION
• Accidents occur in healthcare settings everyday
despite efforts to reduce medical errors.
• A good hospital establishes a culture of safety
that
 Acknowledges and reports medical errors and near misses.
 Promotes teamwork among all staff members.
 Ensures effective communication between staff and patients
that creates a more patient-centered environment.
 Enhances consistency and standardization in the delivery of
health care. *
*National Quality Safety Forum website. www.nashp.org/Files/GNL50.pdf. and Joint
Commission on Accreditation of Healthcare Organization of safety Facts and 2007
Patient Safety Goals.
We must inform our patients ahead of
time!
• Upon admission, we must inform our patients
that, despite our best efforts, no treatment is
without risk or carries a 100% guarantee of
success.
• This fact, though hard to accept especially for
very ill or anxious patients, means that patients
must take an active role in their care.
• Part of the information that patients must receive
upon admission is how they will be informed of
unexpected outcomes.
Why disclose unexpected outcomes to
patients?
• Because it is the right thing to do
• Because patients / families have the right to
actively participate in their care
• Because patients can make rational decisions
about their care only if they know the facts about
their current condition
• Because timely disclosure preserves the
doctor/patient relationship and rebuilds trust
th
5
Disclosure is the
of 8
steps in our response
EIGHT STEPS TO RESPOND TO UNEXPECTED
OUTCOMES
1. Care for the patient
2. Preserve the evidence
3. Document in the medical record
4. Report the event
5. Disclose factual information
6. Analyze the event to prevent recurrence and/or
improve outcome
7. Follow Through with subsequent disclosure
discussion(s)
8. Heal the Health Care Team
The AP plays a central role in all
of the steps
The Attending Physician must ENSURE COMPLIANCE
to policies in
1. Caring for the patient
2. Preserving the evidence
3. Documenting facts in the medical record
4. Reporting the event
5. Disclosing factual information
6. Analyzing the event to prevent recurrence and/or
improve outcome
7. Following through with subsequent disclosure
discussion(s)
8. Healing the Health Care Team
TAKING CARE OF THE PATIENT
AFTER AN ADVERSE EVENT
• Health care team must address current
health care needs
• AP must obtain necessary referrals
• AP must confirm who has primary
responsibility for care
• AP must tell patient / family of any changes
in the health care team
PRESERVING THE EVIDENCE
Residents and nurses must
• Sequester machinery (pumps, anesthesia
machines) and preserve settings
• Sequester equipment (syringes, IV tubing,
medication vials)
• Activate or acquire back-up equipment
DOCUMENTING IN THE MEDICAL
RECORD
What to Include:
 “Known Facts” about adverse event
 Care given in response
 Treatment and follow-up plans
What Not to Include:
 Subjective feelings or beliefs
 Avoid speculation or blame
 References to Incident Report or Sentinel Event
Analysis
 “Confidential” information
REPORTING ADVERSE
EVENTS
• Call Safety hotline Local 8777
• Or inform Medical or Nursing Services Group
heads, Unit Head AND Department Chair
• Or submit a Sentinel Event Report to Medical
Quality Improvement Office (MQIO)
– Do Not Place in Medical Record or Discuss in Medical Record
 Do Not Photocopy
6. ANALYZE for Root Causes to Prevent
Recurrence and/or Improve Outcome
• Patient Safety Goal: Make it hard for Unanticipated Outcome to
occur, easy to detect, easy to respond and report
• Identify all causes of event or “Near Miss”
• Develop and implement Corrective Action Plan (CAP) or refer to
individual/committee responsible for CAP
• Keep RCA and peer review documents and discussions
“confidential”
 Do not include or refer to to RCA or peer review findings in the
Medical Record
 Do not photocopy
7. FOLLOW THROUGH:
Subsequent Disclosure Discussion
The AP, supported by the Medical Services group and Risk
Management Office, is responsible for subsequent
disclosure discussion.
• Goal: Meet ongoing Health Care Needs and continue to
address patient’s/family’s questions, concerns
• Keep Promises: Call Back as promised or as needed
• Keep Promises: Hold subsequent Disclosure Discussion(s)
as promised or as needed, preferably within 3-4 weeks
from time of complaint
 Determine the “Who, When, and Where” of the Disclosure
Discussion based on current patient needs and latest
results of Event Analysis
 Begin subsequent Disclosure Discussion(s) by informing
patient/family how their questions, concerns are being
addressed
 Tell patient that there are administrative policies and
mechanisms to handle these situations
8. HEAL the Health Care Team
Staff members will be trained and
supported in dealing with the
consequences of disclosure.
Advice to staff members
• Acknowledge Effect on Health Care
Team Members
 Unanticipated Outcomes are disturbing
to all involved
 Recognize needs to discuss feelings
about outcome with your family, friends,
and colleagues
 Identify resources to help in healing
 Allow time for resolution of feelings
• Distinguish between discussion of your
feelings and facts of care
MAKING AN INITIAL DISCLOSURE TO
PATIENT / FAMILY
When to disclose?
The need for disclosure must be considered
whenever any one of these instances occur:
1. When a patient experiences an unexpected
outcome of care
2. When a patient experiences significant
complications arising from a confirmed
mistake
3. When disclosure of such information is
important to a patient’s well-being or relevant
to future treatment
MAKING AN INITIAL DISCLOSURE
TO PATIENT / FAMILY
Who will inform Patient?
1. Whenever any 1 of the 3 conditions apply,
the Attending Physician must initiate the
disclosure protocol and inform the MSG
leadership of disclosure plans
2. The Attending Physician is mainly
responsible for disclosing information to
patient/family. If AP is not immediately
available, staff members on duty must
exert all efforts to personally inform
him/her of the adverse event.
3. If no physician-patient relationship exists
at the time of the adverse event, the
hospital Risk Manager can designate the
person/s who will communicate with
patient / family.
MAKING AN INITIAL DISCLOSURE
TO PATIENT / FAMILY
Who will inform Patient?
Aside from the AP, the initial disclosure meeting
may include the ff:
 Health care provider(s) involved in the
adverse event
 Provider(s) with responsibility for ongoing
care
 Person(s) with ability to answer questions
The Risk Management Office and Customer
Service Department may assist persons
involved in Disclosure Discussion in
preparing, coordinating or conducting
discussion, depending upon:
 Communication skills
 Rapport with patient and family
 Language barriers
MAKING AN INITIAL DISCLOSURE
TO PATIENT / FAMILY
Who will inform Patient?
Persons involved in Disclosure Discussion may
need assistance in preparing, coordinating
or conducting discussion, depending upon:
 Communication skills
 Rapport with patient and family
 Language barriers
The MSG leadership may recommend to
the AP the persons who will assist the
AP in the Disclosure Discussion.
MAKING AN INITIAL
DISCLOSURE TO PATIENT /
FAMILY
What should be disclosed?
Disclose only factual information.
The extent of factual information to be disclosed
should be determined by how much is needed
for a patient / family to make reasoned
decisions about their care at the time of
disclosure.
As soon as an adverse event occurs and disclosure
is deemed necessary, the AP must conduct an
educational / psychosocial needs assessment to
determine the content, timing and manner of
disclosure.
MAKING AN INITIAL DISCLOSURE TO
PATIENT / FAMILY
What are factual information?
 Objective Information
Documented in Medical Record
Learned through the Event Analysis
unless “Confidential”
– Outcome and prognosis
The AP and rest of discussion disclosure team
must clarify beforehand what is “Confidential”
and who will discuss what with the
patient/family.
MAKING AN INITIAL DISCLOSURE TO
PATIENT / FAMILY
How to disclose Unanticipated Outcomes?
 Express empathy
 Convey compassion for patient’s and family’s
pain and suffering
“I’m sorry that you…” or “I am sorry that
this happened…”
Focus on patient’s and family’s needs
Avoid “I am sorry that I…”
– Extend sympathy to family of deceased
patient
– May express verbally or in writing
– May send flowers
– May attend funeral
MAKING AN INITIAL DISCLOSURE TO
PATIENT / FAMILY
What NOT to disclose

What not to communicate
 Subjective information
 Conjectures or beliefs
 “Confidential” information, such as
a. Results of protected Peer Review, Quality
Improvement, or Risk Management
Committees deliberations
b. Information provided in confidence by a third
party
c. Confidential information about a health care
organization or its operations
d. Health or employment information about a
provider or employee (201 files)
MAKING AN INITIAL DISCLOSURE TO
PATIENT / FAMILY
What NOT to disclose
• Speculation and blame
 Cause(s) of unanticipated outcome may not always be
preventable
 May be result of disease process or risky life-saving
treatment, or not preventable e.g. some falls)
 Unanticipated outcome is not always due to negligence
 Error, if one occurred, may not be cause of unanticipated
outcome
• Results of administrative actions
– Findings of investigations
– Sanctions applied to staff
– Tell patient this is confidential information
What staff must do when
communicating to patients
1. Contain own emotional response
2. Focus on patient’s needs
3. Convey receptive attitude (open posture: arms
uncrossed, concerned expression, eye contact)
4. Avoid defensive or accusatory reaction if care is
questioned
5. Acknowledge that an adverse event has
occurred
6. Acknowledge that the patient is unhappy with the
outcome
7. Express regret for what has occurred
What staff must do when
communicating to patients
8.
Plan for follow-up care and more discussions and
communicate the plan. If cause of unanticipated
outcome or prognosis is not yet known, assure
patient/family that additional facts will be shared
when available.
9. Give estimate of how long analysis process may
take if asked.Patient expectations may not be
realistic. If expectations not met, can lead to
breakdown of trust, fear of abandonment or coverup, patient dissatisfaction, lawsuit. Make
appointment for phone call and/or visit to update
patient. “I will call you in two weeks (for example) to
give you an update.”
10. Encourage patient/family to call if they have
questions or have not heard back from provider.
11. Give name of contact person in hospital.
What staff must do when
communicating to patients
12. Respond to patients complaints
1. Assure patients that TMC staff are dedicated to
quality care and take patient’s complaints seriously
2. Refer complaint to Customer Service Department
3. Explain how to lodge complaint
4. Do not offer opinion on need for Lawsuit or Worth of
injury
13. Verify patient’s/family’s understanding of outcome and
prognosis
“This is upsetting news. I want to make sure that I have
clearly communicated what we know so far. What is
your understanding of what happened? About your
current condition?”
Critical elements to support
open disclosure
• Honest and ongoing communication
• There is an exemption from disciplinary action for
those professionals reporting adverse events or
medical errors, except where there is a criminal offence
• Legal privilege is provided for reports and information
identifying adverse events
• Quality improvement processes
A system that supports open
disclosure must result in
1.
2.
3.
4.
5.
6.
7.
Lesser likelihood of litigation
Feeling relief from guilt
Promoting trust
Strengthening doctor-patient relationships
Provide an environment where patients and their
support person receive the information they need to
understand what happened
Professionals learn from errors
Professionals can be given support
A system that supports open
disclosure must result in
8.
Creating an environment where patients, health
care professionals and managers all feel supported
when things go wrong
9. Building investigative processes to identify why
adverse events occur
10. Bringing about any necessary changes in systems
of clinical care, based on the lessons learned
For hospital staff, open
disclosure must
 Be planned and/or closely supported by staff who
have received open disclosure training or have
experience in carrying out open disclosure
 Be managed and supported by the Risk
Management Office, Customer Service Department
and Safety Office
 Involve senior clinical staff
 Be conducted by staff who have excellent
communication and listening skills
For hospital staff,
open disclosure must
 Be conducted in circumstances where
clinicians involved in the adverse event
have already established a good relationship and
understanding with the patient and the patient’s
family
 Be a sub-component of an established clinical
governance system
 Encompasses careful pre-planning, responding to
patient needs, adequate follow-up, and internal as
well as independent counseling support
 Include consideration of paying for patients’ and/or
family members’ immediate expenses
For hospital staff,
open disclosure must
Address professional barriers, such as
• Litigation fears – malpractice liability
• Disciplinary criticism and/or action
• Lack of commitment by top management
• Lack of explicit staff and manager support
• Being reported to external organizations
• Not knowing how to talk to patients regarding error
• Lack of institutional support
• Fear of risk to reputation
• Loss of respect from peers/colleagues
• Anxiety of exposing individual fault
• Fear of loss of referrals
• Fear of reprisal for whistle blowing
• Fear of punishment for breaching professional code of silence
For patients, open disclosure
must
• Allow staff to show respect to the patient / family by
offering an immediate and sincere expressions of regret
• Be conducted as much as possible by those originally
involved in the patient's care
• Allow patients to indicate the matters they want to see
clarified and action taken on
• Allow staff to give carefully structured timely feedback
For patients, open disclosure
must
• Prevent the fragmentation of health care by
a) preventing different staff from expressing conflicting
perspectives on the causes of the adverse event
b) preventing revelations of adverse events to outside
institutions without pre-emptive communication with TMC
c) minimizing different staff engaging consumers in repeated
questioning about the case
• Involve staff who are good listeners and ensure patients /
family can express their grief, guilt or anger
Summary of presentation
• Open and timely disclosure rebuilds the trust of
patients and their families after an unexpected
outcome.
• Timely and effective disclosure of unexpected
outcomes to our patients depends on
– Visible and sustained support from management and
the entire hospital system
– Attending Physicians who are enabled and supported
by the hospital
– Enlightened patients who are co-responsible for their
care
– Substantial and direct relationship to quality
improvement and patient safety programs
Are you ready to reclaim your
patient’s trust?(select all correct answers)
1. The following are examples of unexpected outcomes
a. Infection following clean surgery
b. Septicemia after perforated appendicitis
c. Excess drug administration
d. Erective dysfunction after prostatectomy
Answer/s?
2. The following are true about unexpected outcomes
a. They always result from medical errors.
b. They are always associated with sentinel events.
c. Staff negligence is often the root cause.
d. None of the above.
Answer/s?
Are you ready to reclaim your
patient’s trust?(select all correct answers)
3. The AP must ensure that the following measures are taken BEFORE
conducting initial disclosure of unexpected outcomes:
A. Continue caring for the patient
B. Sequester any equipment or drugs involved in the adverse event.
C. Document facts in the medical record
D. Report the event to the Safety or the Risk Management Office
Answer/s?
4. The AP must ensure that the following measures are taken AFTER
conducting initial disclosure of unexpected outcomes:
a. Plan for subsequent disclosure.
b. Help analyze the adverse event to prevent recurrence.
c. Help heal the health care team.
d. Participate in quality improvement and safety efforts.
Answer/s?
Are you ready to reclaim your
patient’s trust?(select all correct answers)
5. The need for disclosure must be considered whenever any one of these
instances occur:
A. When a patient experiences an unexpected outcome of care
B. When a patient experiences significant complications arising from a
confirmed mistake
C. When disclosure of such information is important to a patient’s wellbeing or relevant to future treatment
D. When disclosure enables a patient to participate in his/her care
Answer/s?
6. In communicating to patients who experience unexpected outcomes staff
members must
A. Contain their own emotional response
B. Focus on patient’s ongoing health care needs
C. Acknowledge that the patient is unhappy with the outcome
D. Express regret for what has occurred
Answer/s?
Are you ready to reclaim your
patient’s trust?(select all correct answers)
7. A system that supports open disclosure must result in
A. Expulsion of all errant staff members
B. Higher levels of trust and openness among doctors and patients
C. Professionals learning from errors
D. Professionals being support before, during and after disclosure
Answer/s?
8. For patients, open disclosure must
A. Allows staff to show respect to the patient / family by offering an
immediate and sincere expressions of regret
B. Enable patients to be compensated or given discounts
C. Allow patients to indicate the matters they want to see clarified and
action taken on
D. Allow staff to give carefully structured timely feedback
Answer/s?
Are you ready to reclaim your
patient’s trust?
Answers:
1. A only
2. D
3. A, B, C, D
4. A, B, C, D
5. A, B, C, D
6. A, B, C, D
7. B, C, D
8. A, C, D
8 out of 8 – trustworthy patient’s
champion!
6 or 7 out of 8 – a budding pride of
The Medical City
4 or 5 out of 8 – you will need help
when your patients experience
unexpected outcomes
2 or 3 out of 8 – you owe it to your
patients and staff to master this
GHP module*
0 or 1 out of 8 – don’t leave without
passing this one*
* Please go over the slides again.
This SIM Card certifies that
______(please overwrite with your name, thank you)__,
MD
has successfully completed the
Self Instructional Module on
Reclaiming your Patient’s Trust
after an Unexpected Outcome.
(Sgd) Dr Alfredo Bengzon
President and CEO
(Sgd) Dr Jose Acuin
Director, Medical Quality Improvement
Suggested support for health
care team
Standing committee to handle concerns
(lawyer, psychiatrist, admin, peers) (admin,
professional, legal, emotional concerns)
Legal retainers for residents, consultants
Psychiatry retainer
Psychiatry to develop debriefing protocol for
health care team