ADMINISTRATION SERIES: MEDICAL ERROR Jay Green Dr. Lisa Campfens March 11, 2010.
Transcript of ADMINISTRATION SERIES: MEDICAL ERROR Jay Green Dr. Lisa Campfens March 11, 2010.
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ADMINISTRATION SERIES: MEDICAL ERROR
Jay Green
Dr. Lisa Campfens
March 11, 2010
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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
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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
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Medical error stats
2004 HQCA Alberta Patient Safety Survey2004 HQCA Alberta Patient Safety Survey
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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
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Adverse EventHarmClose CallMedical Error
Canadian Disclosure Guidelines. Canadian Disclosure Guidelines. Canadian Patient Safety InstituteCanadian Patient Safety Institute
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Guiding Principles
Autonomy
Patie
nt Cen
tere
d Car
eHonesty
Tran
spar
ency
Trust
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Human Error
Reason. Human error: models and management. Reason. Human error: models and management. BMJBMJ 2000;320:768-70 2000;320:768-70
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Error prevention?
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Small group cases #1
10 minutes Cases 1 & 2
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Management of Serious Adverse Events
iweb.calgaryhealthregion.ca/qshi
Immediate management: RESPOND
Continuing management: ACE
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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
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Just & Trusting Culture
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Safety Learning Report
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Disclosure
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Disclosure = ?
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Disclosure: Underlying Principles
Hickson, 1992; Beckman, 1994; Vincent, 1994; Kraman, 1999; Gallagher, 2003
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What does it mean?
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Why don’t we want to do it?
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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
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Who does it?
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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
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Apology
“Apology is not an ethical right, but a therapeutic necessity” – Lucian Leape
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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”
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Disclosure Tips
Set the tone Timeliness Privacy Setting Body language Be in control, but not controlling Simple, slow Interactive Avoid speculation Describe next steps
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AHS Procedures for Disclosing Harm to Patients
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Canadian Medical Protective Association Information Sheet, March 2005Canadian Medical Protective Association Information Sheet, March 2005
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Case discussion
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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
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The END
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