AnnMarie Papa, DNP,RN,CEN,NE-BC,FAEN, FAAN

AnnMarie Papa, DNP,RN,CEN,NE-BC,FAEN, FAAN

} Explore impact of medical errors } Discuss importance of clear and effective communication } Formulate strategies to support healthcare professionals involved in medical errors

Seek first to understand then to be understood Stephen Covey

} Many interacting parts } Difficult to predict behavior } Human factors } Multiple competing priorities } Interruptions

} Less than one death per 100,000 Nuclear power Railroads in Europe Scheduled airlines

} One death in less than 100,000, but more than 1000 Driving Chemical manufacturing

} More than one death per 1000 Bungee jumping Mountain climbing Healthcare

} James Reason Safe is everyone's business Blame free Top management proactive Training in recognition and recovery of errors Mental and technical training for safe and effective performance Rapid useful and intelligible feedback

} Human beings are fallible } We are susceptible to human error and behavior drift } Tenets of Just Culture Human error At-Risk behavior Reckless behavior

Human Error Inadvertent Educate, redesign At Risk Behavior Mistaken belief or choice Remove at risk incentives, increase situational awareness Reckless Behavior Conscious disregard Remedial or punitive action

} Fallibility is part of the human condition } We cannot change the human condition } We can change the conditions under which human s work

} Characteristics Preoccupation with failure Commitment to resilience Sensitivity to operations Culture of safety

} Key principles Maintain a uniform culture of safety Utilize optimal structures and procedures Provide intensive and continuing training for individuals and teams Conduct thorough organizational learning and safety management

To Err Is Human Kohn LT, Corrigan JM, Donaldson MS, Eds. To Err Is Human. Washington National Press, Wash, DC. 2000.

Extra Extra Airlines expect 1-2 jets to crash daily Over 1000 deaths expected weekly = 44,000 98,000 deaths annually due to medical errors

www.cdc.gov/nchs/fastats. Accessed Jan 2012. Based on 2007 data. How medical errors rank as cause of mortality Heart 616,067 Cancer 562,875 Stroke 135,952 Accidents 123,706 Medical Errors ~100,000 Alzheimer's 74,632 Lung 127,924 Diabetes 71,382

} First introduced by Dr. Albert Wu in 2000 Error occurs Lack of sympathy from colleagues Blame regardless of circumstance Viewed as incompetent Develop feelings of guilt and inadequacy

} Unanticipated adverse event } Medical error and/or a patient related injury } Traumatized by event } Difficulty coping with emotions

} Confusion } Detachment and/or withdrawal } Grief and/or depression } Shame and/or guilt } Anger and/or confusion } Re-living the event

Not IF but WHEN!

} Chaos and accident response } Intrusive reflections } Restoring personal integrity } Enduring the inquisition } Obtaining emotional first aid } Moving on

Symptom % Reporting Extreme fatigue 52% Sleep disturbance 45% Rapid heart rate 42% Increased blood pressure 42% Muscle tension 35%

Symptom Frustration 77% Decreased job satisfaction 71% % Reporting Anger and/or sadness 68% Difficulty concentrating 65% Flashbacks 65% Loss of confidence 65% Repetitive intrusive memories 52% Second guessing career 39% Excessive excitability 32% Scott et al. 2009

} Treatment that is just } Respect } Understanding and compassion } Supportive care } Transparency and opportunity to contribute

} Stigma to reach out for help } Little time to pause and reflect } Intense fear of unknown } Fear of collegial relationship compromise } Fear of future legal woes

} Patient and Family } Staff } Organization

} Empathy } Full disclosure } Support } Assessment of needs } Apology } Resolution } Learning } Continuous improvement

} Critical thinking } Deductive reasoning } Increase self awareness } Understanding of values } Competence development } Dynamic framework } Knowledge acquisition

No law or ordinance is mightier than understanding Plato

Innovation Series 2011 Respectful Management of Serious Clinical Adverse Second Edition Events Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. (Available on www.ihi.org) 21

} Encourage and help every organization to develop a clinical crisis management plan before they need to use it; } Provide an approach to integrating this plan into the organizational culture of quality and safety, with a particular focus on patient- and familycentered care and fair and just treatment for staff; and } Provide organizations with a concise, practical resource to inform their efforts when a serious adverse event occurs in the absence of a clinical crisis management plan and/or culture of quality and safety.

29 Innovation Series: Respectful Management of Serious Clinical Adverse Events (Second Edition) Appendix A: Respectful Management of Serious Clinical Adverse Events Checklist Element Dimension Started 4 Organizational Culture of Safety Internal Notification Crisis Management Team (CMT) Priority 1: The Patient and Family Have expectations been set? Are board and leadership accountable? Are there established systems, policies, and a crisis management plan? Have the CEO, Executive Leaders, Risk Management, QI and Patient Safety, PR, Legal Counsel, and other relevant leaders been notified of the event? Has the board of trustees been notified? Has the threshold been met for activation of the CMT? Is the team membership in place? What executive leadership will chair the team? Is there a need for an independent facilitator? Completed 4 Who is the organizational 24/7 contact person for the patient and family? Has the organization acknowledged the pain, expressed empathy and regret? Are the immediate needs of the patient and family met? Has the patient had a full clinical assessment? Has the organization assessed the personal safety of the patient and family? Has the patient s primary care physician and extended care team been notified? What is being heard from the patient and family? Has the organization apologized, as appropriate? Does the organization understand what the patient and family want said to others about the event? Is the organization providing ongoing support to the patient and family, including reimbursement of out-of-pocket expenses? Is the organization prepared to have open discussions about compensation, if deemed appropriate? Has the family been engaged in the immediate investigation and then invited to participate in the root cause analysis (RCA) of the event? Has the organization suppressed all normal PR and other communications to the patient or family that could inflict further pain? NOTE: This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged. (continued on next page) 2011 Institute for Healthcare Improvement

Appendix B: Respectful Management of Serious Clinical Adverse Events Work Plan: Elements, Dimensions, and Milestones Element Dimension Pre- Event First Hour First Day First Week First Month Activities after First Month Organizational Culture of Safety Board and Leadership Trust, Respect, Human Rights, Forgiveness, Repentance Learning and improvement Systems, Policies, Procedures, Guidelines, Crisis Management Plan Internal Notification CEO, Executive Leaders, Risk Management, QI and Patient Safety, Counsel, Communication, etc. Crisis Management Team Priority 1: The Patient and Family Approve Assemble Annotate Annotate Annotate Revise Learning System Activated Engaged and Visible Engaged and Visible Engaged and Visible Learning and improvement Board Pending Activated Updated Updated Learning and improvement Threshold Met for Activation Plan Activated Meeting Schedule Schedule Stand down with plan Membership Plan Activated Refine Refine Updated Chair Plan Activated Refine Ongoing Ongoing Facilitator Plan Activated Ongoing Ongoing Ongoing Formal debrief Revise plan Who s on Point Establish Report Report To resolution and learning, including any external Acknowledged Pain, Expressed Acknowledged Ongoing Ongoing professional or judicial Regret actions Patient/Family Needs Meet Established Ongoing Ongoing Patient Fully Assessed Assessed Update Update Personal Safety Assess Update Update Primary Physician Notified Notified Update Update Hearing What Report Report Report Apology Extended Assessment Assessment Assessment What Do They Want Said Establish Update Update Provide Ongoing Support, Reimbursements Offer Update Update NOTE: This work plan is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged. (continued on next page) 2011 Institute for Healthcare Improvement Source: Conway J, Federico F, Stewart K, Campbell M. Respectful Management of Serious Clinical Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. (Available on www.ihi.org)

Appendix C: Respectful Management of Serious Clinical Adverse Events: Disclosure Culture Assessment Tool Element** Y Y/N N Internal Culture of Safety The organization, board, and leadership are grounded in the core values of compassion and respect, and the responsibility to always tell the truth. Harm is seen as the failure of systems and not people, and is considered in a fair and just culture with policies and practices. Malpractice Carrier Policies, Guidelines, Procedures, Practices There is a commitment to rapid disclosure, compensation, and support. There is a written understanding of how cases will be managed with carrier. Mechanisms are in place for rapid, respectful resolution. There is a policy on patient and family compassionate communications. Informed consent policies and practices are up-to-date and effective. There is a policy on patient and family partnerships. There are policies on disclosure and documentation. There are procedures in place for internal and external communication. Guidelines/policies support a fair and just culture, and reporting of adverse events. Root cause analyses commence immediately, are closely managed with an executive sponsor. Results are shared, including with the patient/family. There is a written crisis management plan. This plan is centrally located. Policies/guidelines exist for reimbursement of out-of-pocket expenses. Training Training programs are in place for all staff on communication, expectations, policies, procedures, guidelines. Disclosure Processes The Disclosure There is just-in-time coaching (training) for disclosures. There is rapid notification of patient/family and activation of support typically, the organization shares what is known about the event. There is a team to support staff in preparing for disclosure. The organization is transparent and honest. Responsibility is taken. We are empathetic, apologize and/or acknowledge. There is a commitment to providing follow-up information. The caregiver is supported throughout the process. Ongoing support is provided for the patient and family. (continued on next page) 2011 Institute for Healthcare Improvement Source: Conway J, Federico F, Stewart K, Campbell M. Respectful Management of Serious Clinical Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. (Available on www.ihi.org)

38 37 Innovation Series: Respectful Management of Serious Clinical Adverse Events (Second Edition) Appendix D: Respectful Management of Serious Clinical Adverse Events: Organizations from Which to Draw Courage and Learning Organization Contact Incident Advocate Lutheran General Hospital, Park Ridge, IL Anthony Armada, CEO Mike McKenna, MD, Vice President of Medical Management Medication error leading to fatal hypernatremia in a neonate Beth Israel Deaconess Medical Center, Boston, MA Kenneth Sands, Senior Vice President Wrong-site surgery Catholic Health Partners, Cincinnati, OH Jana Deen, Patient Safety Officer Preventable death of parent of health Cincinnati Children s Hospital Medical Center, Cincinnati, OH Michael A. Fisher, President and CEO Uma R. Kotagal, Senior Vice President, Quality, Safety and system executive Preventable death: Flushing with alcohol instead of saline Transformation Children s Hospital Boston, Boston, MA Sandy Fenwick, President Adverse events leading to death Clarian Health System, Indianapolis, IN Dan Evans, CEO Heparin overdoses leading to death Contra Costa Regional Medical Center, Martinez, CA Anna Roth, CEO Violence during care delivery leading to death of a nurse Dana-Farber Cancer Institute, Boston, MA Saul Weingart, Vice President, Quality and Patient Safety Chemotherapy overdose; theft of patient information Steven R. Singer, Senior Vice President of Communications Duke University Health System, Durham, NC Karen Frush, Chief Patient Safety Officer Adverse events leading to harm and death Immanuel St. Joseph Health System, Mankato, MN Greg Kutcher, CEO Drug diversion from multiple patients Johns Hopkins Medical Center, Baltimore, MD Peter Pronovost, Director of the Quality and Safety Preventable death of a child Research Group Mt. Auburn Hospital, Cambridge, MA Jeanette Clough, CEO Aberrant physician behavior, credentialing Novant Health, Winston-Salem, NC Paul Wiles, CEO MRSA infection in the NICU, leading to the death of children New York City Health and Hospital Corporation, New York, Alan D. Aviles, President and CEO Unrecognized death in Psychiatric ED NY Rady Children s Hospital, San Diego, CA Blair Sadler, Past President Sexual abuse of children by employees Virginia Mason Medical Center, Seattle, WA Gary Kaplan, CEO Preventable death Detailed information on each organization s story and other resources are available on IHI s website at: http://www.ihi.org/knowledge/pages/tools/leadershipresponsesentineleventeffectivecrisismgmt.aspx. Winchester and Eastleigh Healthcare NHS Trust, UK Kevin Stewart, Medical Director Additional stories Two maternal are also deaths included in: Johnson RL. Crisis Communication: Case Studies in Healthcare Image Restoration. HCPro, Inc.; 2006. Wojcieszak D, Saxton JW, Finkelstein MM. Sorry Works! Disclosure, Apology, and Relationships Prevent Medical Malpractice Claims. AuthorHouse; 2010. [See Chapter 9: The Realized Benefits of Disclosure Success Stories.] 2011 Institute for Healthcare Improvement

} First, Do No Harm! } Never lose sight of the staff } Speak up } Provide 24/7 resources } Work collaboratively to figure it out } Keep eyes open } Listen, listen, listen

An intelligent person is never afraid or ashamed to find errors in his understanding of things Bryant McGill

} MITSS Toolkit http://www.mitss.org/ } ISMP referral http://ismp.org/ } IHI white paper http://www.ihi.org/knowledge/pages/ IHIWhitePapers/ RespectfulManagementSeriousClinicalAEsWhitePape r.aspx } Second victim response team

Thank You ampapa109@hotmail.com