Transcript Risk Management

HOUSE STAFF ORIENTATION
2016
Charles Conklin
Director, Risk Management TUHS
John R. O’Donnell, Esquire
Senior Counsel TUHS
Topics
• Incident reporting
• Ethical concerns
• Informed Consent
– Capacity
– Surrogate Decision Makers
• Advanced Directive Proxy, Power of Attorney
• Legal Guardians, Health Care Representative
• End-stage medical condition, permanent
unconsciousness
What is Risk Management?
A coordinated system-wide process which
identifies, prevents, or minimizes events that
may present potential risk to our patients,
visitors, volunteers, and staff.
Incident Reporting
Incident Reporting
• An incident report should be filed for any of
the following issues/conditions
– Any untoward outcome/harm to a patient not expected
in the normal course of treatment including near misses
• Complications of procedures, medication misadventures,
iatrogenic injuries
– Risk Management reviews all incidents filed in the
system and may follow-up w/ you if clarification is
necessary.
– For very serious incidents, Root Cause Analysis may be
conducted and your participation may be required – this
is a non-punitive peer review protected process
Incident Reporting
• Electronic On-Line reporting system
– MIDAS
– Available on all desktops as well as TUHS Employee Home
Page under references
– Report should be filed as soon after the incident as possible
before the end of shift - 24 hours
– Report should contain only the facts, no opinions, should be
objective not subjective – personal comments are not
appropriate
– May be entered anonymously by title only
Ethics Consults
Ethics Consults
• The Ethics Committee membership will
schedule an ethics consult when requested.
Issues involving the need for an ethics consult
may include:
– End of Life Decision Making
– Withdrawal of care
– Conflicts of care decision between family and/or
medical team
• You should enter an order to request a consult
and you can call the Risk Management Dept.
Informed Consent
Medical Care Availability and Reduction
of Error Act (MCARE-Act 13)
• 1303.504 Informed Consent
• Duty of Physicians—except in emergencies a
physician owes a duty to a patient to obtain
the informed consent of the patient or the
patient’s authorized representative prior to
conducting the following procedures:
• (1) Performing surgery, including the related
administration of anesthesia
• (2) Administering radiation or chemotherapy
Informed Consent Cont’d…
• (3) Administering a blood transfusion
• (4) Inserting a surgical device or appliance
• (5) Administering an experimental medication,
using an experimental device or using an
approved medication or device in an
experimental manner.
Informed Consent Cont’d…
• Description of Procedure
• Consent is informed if the patient has
been given a description of a
procedure as set forth in Duty of
Physician and the risks and
alternatives that a reasonable prudent
patient would require to make an
informed decision as to that procedure.
Lack of Informed Consent
• Constitutes a battery which is an
unwanted/unauthorized touching of the
patient.
• Consent form must be complete. If not
recorded it was not said.
• The duty to obtain informed consent is nondelegable. Must be obtained by a physician or
where appropriate a physician extender.
Case Example
• Ophthalmologist recommends LEFT Temporal Artery Biopsy (TAB)
• Ophthalmologist verbally advises vascular surgeon of need for RIGHT
TAB
• Vascular accepts for RIGHT TAB
• Ophthalmology office correctly completes OR booking and preadmission
testing order for LEFT TAB
• OR schedule reflects LEFT TAB
• Laterality not noted on H & P or Informed Consent
• Vascular surgeon notes indicate RIGHT TAB
• Time-out in OR confirms RIGHT TAB to be performed
• RIGHT TAB performed resulting in wrong site surgery
CAPACITY
- A patient is deemed to have capacity when
the following conditions exist:
• Understands the potential material benefits,
risks and alternatives involved in a specific
proposed health care decision.
• Makes that health care decision on his/her
own behalf.
• Communicates that health care decision to
any other person.
CAPACITY
This determination can be made by
any treating physician and does not
necessarily require a psychiatric
evaluation
Surrogate Healthcare
Decision Makers
– A Surrogate Decision-maker is a
person designated by law to make health
care decisions and consent to care on
behalf of the patient. Surrogate Decisionmakers fall into one of three categories:
(1) Agent; (2) Guardian (3) Health Care
Representative
Agent
An Agent is someone selected by the
principal (i.e. patient), when the
principal had capacity, in an advance
health care directive (i.e. Power of
Attorney or Living Will).
Guardian
- A Guardian is someone who is
appointed by the Court to make
decisions on behalf of an
incapacitated person. A Guardian
will have a Court Order designating
them as the Guardian for the person
who lacks capacity.
Health Care Representative
- A person who is at least 18 years of age can be
a health care representative and may make a
health care decision for an individual whose
attending physician has determined that the
individual lacks capacity. Health Care
Representatives may be used after determination
that there is no guardian appointed by the Court,
there is no Health Care Power of Attorney or a
Health Care Power of Attorney is not reasonably
available.
Health Care Representative Cont’d…
• Any member of the following classes, in descending order of
priority, who is reasonably available, may act as health care
representative:
• (i)
The spouse, unless an action for divorce is pending, and the
adult children of the patient who are not the children of the
spouse.
• (ii)
An adult child.
• (iii) A parent.
• (iv) An adult brother or sister.
• (v)
An adult grandchild.
• (vi) An adult who has knowledge of the patient's preferences and
values, including, but not limited to, religious and moral
beliefs, to assess how the patient would make health care
decisions.
SURROGATE DECISION MAKERS
• Legal Guardians and Healthcare
Representatives may not withdraw or withhold
medical care (e.g. DNR) unless the patient is
(1) Permanently unconscious (PU) or (2) is
suffering from an end stage medical condition
(ESMC). Either a PU or ESMC must be
verified by two physicians.
Summary
• Risk Management On-Call 24/7
• Incident Reporting
• Ethics consults
• Informed Consent
– Capacity
– Surrogate Decision Makers
• Advanced Directive Proxy, Power of Attorney
• Legal Guardians, Health Care Representative
• End-stage medical condition, permanent
unconsciousness
Risk Management Departments
• TUH – Main Campus
– Risk Management on-site
• 8am- 12midnight M-F, 8am-8pm Saturdays & Sundays
– Risk Manager On-Call 24/7
• TUH – Episcopal & Northeastern Campuses
– Risk Management on site
• 8:30am – 5pm
– Risk Manager On-Call 24/7
• TUH – Jeanes & Fox Chase
– Risk Management on site
• 8:30am – 5pm
– Risk Manager On-Call 24/7
Questions ? ?