More than just disclosure Supporting residents following a harmful patient safety incident I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. Je n ai aucune affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d appareils médicaux ou un cabinet de communication. Dr. Ellen Tsai, Physician Advisor, Practice Improvement, CMPA ICRE Co-Developed Workshop September 30, 2016 Faculty / Presenter Disclosure Learning objectives Faculty: Employee of: Relationships with commercial interests: - Grants / Research Support: none - Speakers Bureau / Honoraria: none - Consulting Fees: none - Other: none Dr Ellen Tsai CMPA Conflict of Interest - I have no financial or professional affiliation with any organization that can be perceived as a conflict of interest in the context of this presentation. Copyright - Not to be distributed without written permission of CMPA. No audio recording, video recording, or photography is allowed without CMPA's permission. Information is for general educational purposes only and is not intended to provide specific professional medical or legal advice or constitute a standard of care. 1. Describe the key elements in the initial disclosure of a harmful patient safety incident 2. Consider strategies to evaluate disclosure-related competencies 3. Identify the needs of the resident as second victim in the disclosure process Media Asset Copyright - All non-cmpa audiovisual files are used with permission and for educational purposes only. All rights belong to the original owner as per license agreements Thinkstock, YouTube and others as required. Disclosure noun dis clo sure \dis-ˈklō-zhər\ It will be one of the hardest conversations you will ever have 1. A process by which harm from healthcare delivery is communicated to the patient or the patient s family, or both. 1
Key messages Key message #1 Why disclose? Professional, ethical and legal obligation Institutional policy Preserve patient-physician trust Right thing to do 1/3 of those who had experienced error reported receiving disclosure or apology The lack of concern for the victim s and their families was far worse for all of us than [if they] had admitted [a] mistake and apologized, which never happened since they would never admit fault. I have no trust in the medical profession now. I suspect every Dr. not knowing if they are really being honest and have my best interests at heart. [Blendon et al. N Engl J Med 2002;347:1933-40.] [Southwick et al. BMJ Qual Saf 2015;24:620-9.] Other reasons to disclose? When should disclosure occur? Healing/closure for caregiver Apologizing might, in fact, be a useful approach to resolving both physician and patient distress after an error. Improve safety The need to tell patients about error s cause and prevention could create stronger links between physicians and safety programs, reducing future errors. Disclose to patient [Gallagher et al. JAMA 2003;289:1001-7.] 2
No evident harm / potential for harm incidents When in doubt ask yourself, Would a reasonable patient or family member want to know? Generally disclose to patient If ongoing safety risk for that patient, or if patient is already aware Disclosure is a process 1 clinical needs 2 Key message #2 3 emotional needs First things first - clinical needs 1 clinical needs Assess and correct safety issues Fix or limit further harm Consider who should provide further care information needs 3
Planning the initial disclosure Who should lead the discussion? Proceed with the meeting as soon as reasonably possible Determine the known facts Confirm if there will be QI review Plan the main discussion points Don t script word for word Anticipate emotions and questions 1. The resident 2. The attending physician 3. The charge nurse 4. Director of risk management 2 information needs Suggestions for getting started: Something unexpected has happened and we need to talk about it I want to talk to you about something that has happened to your son information needs Establish what the patient already knows Present the known facts Nature of the event Level of severity Impact on patient Hindsight and hindsight bias The puzzle is solved, the final diagnosis is clear Medical errors most often result from a complex interplay of multiple factors. Only rarely are they due to the carelessness or misconduct of a single individual. BEFORE arriving at a final diagnosis AFTER determining the final diagnosis AFTER a delay in making a diagnosis or a misdiagnosis Dr. Lucien Leape 4
x information needs Stick to the facts Avoid speculation Don t blame Comment only on your own involvement 3 emotional needs Allow the patient to express their feelings and perspective Identify and propose support measures as needed Let the patient know you care and are taking the situation seriously Ending the meeting Next steps Timelines Follow-up and contact information Key message #3 Saying I m sorry CMPA advice Goal of apology is not to prevent complaints or lawsuits Time August 15, 2005 Vol. 166 No. 7 5
Which of the following is an appropriate apology? 1. I m so sorry that the nurse gave you the wrong medication. 2. It s all my fault that you had a heart attack. 3. I regret that this has happened to you. 4. This is difficult for me as well. What is an apology? A genuine expression of sympathy or regret, a statement that one is sorry for what has happened. What apology is not emotional needs I m sorry that this happened to you Beware of: I m sorry but that you feel this way that I didn t that my colleagues Apology legislation Disclosure is a process Text here Text here 6
Incident Disclosure discussions 10/14/2016 Post analysis disclosure Last but not least document! If analysis confirms responsibility, apology may include admission of responsibility THE WRONGS : Wrong patient, procedure, side or site (digit, limb, organ); wrong drug, dose or route; wrong administrative practice Objective details Patient s condition Clinical interventions Who has been notified Date, time, place Who attended Facts presented Patient s response Questions raised Follow-up plans Key messages 1 clinical needs 3 emotional needs 2 information needs Evaluating disclosurerelated competencies CanMEDS Communicator CanMEDS Milestones 3.2 Disclose harmful patient safety incidents to patients and their families accurately and appropriately Copyright 2015 The Royal College of Physicians and Surgeons of Canada. http://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e. Reproduced with permission. 7
www.cmpa-acpm.ca www.cmpa-acpm.ca/gpg Handout role 1 Emergency physician You are upset the nurse gave the wrong dose of morphine but grateful the patient fully recovered. You need to explain the event and reassure the patient that there will be no long-term complications. How do you proceed? Handout role 2 Registered Nurse (RN) You are very upset that you administered the wrong dose of morphine. You could not read the physician's order. You had questioned the dose but the physician was distracted and simply told you to go ahead as ordered. You are not sure what role you will play in the disclosure discussion. How do you proceed? Handout role 3 Nursing supervisor You will be taking the lead for the junior nurse in the upcoming disclosure discussion. Remember to support the junior nurse while acknowledging the adverse event. How do you proceed? Handout role 4 Patient You are now fully alert after a 4-hour period of monitoring. You have no idea what happened. You are capable of understanding the discussion and, when asked, you do not want anyone else to be present to hear Potential debrief questions Did the nursing supervisor and emergency physician: plan what they might say prior to speaking with the patient? ask if the patient would like anyone to be with her to hear this news? provide an opening acknowledgement that something unexpected has happened? discuss the facts without blaming one another or speculating as to what contributed to the adverse event? acknowledge the patient's emotions? check for understanding? welcome questions? indicate how seriously they were taking the situation? apologize? define the next steps to determine how this might be prevented in the future? this. 8
Checklist Disclosure of a harmful patient safety incident Missed mammogram Acknowledges that something unexpected has happened Asks first what patient/family knows about the situation Presents objective facts without blame or speculation Acceptable Needs improvement Not done https://www.youtube.com/watch?list=pln6q6 RfYBIXXhBnocjx8UfJWm6zcLgob5&v=tlaEz RkyoMs Discusses revised plan of care (including transfer to another provider, if appropriate) Allows patient/family to express feelings, demonstrates genuine concern Expresses regret (e.g. I am sorry that this has happened. ) Shares information using appropriate language Checks for understanding Provides opportunity for patient/family to ask questions Appropriately closes meeting (next steps, timelines, follow-up plan) Overall rating Evaluating competency Role play exercises Simulation using standardized patients (SP) Real-time observation and feedback Review quality of documentation Video vignette study comparing nonverbal disclosure styles (highly involved vs. highly uninvolved) Error perceived as more severe Apology less sincere More likely to blame MD Less prone to forgiveness More likely to seek legal advice [Hannawa et al. Soc Sci Med 2016;156:29-38.] Entrustable Professional Activities Can demonstrate the required knowledge, skills and attitudes Knows when to ask for additional help Can be trusted to seek assistance in a timely manner EPA Disclosure of a harmful patient safety incident Plan the initial disclosure meeting Disclose accurately and appropriately Apologize appropriately Develop a patient-centred follow-up plan Document the disclosure discussion(s) [https://www.ranzcp.org/pre-fellowship/2012-fellowship- Program/Assessment-overview/Entrustable-Professional-Activities.aspx] 9
A dilemma? The right thing to do vs. Fear of being punished The resident as second victim Resident disclosure survey 31% of residents reported apologizing for situation associated with error Only 17% disclosed medical error to patients or family 12% reprimanded by attending 16% reprimanded by another resident [Kronman et al. BMJ Qual Saf 2012;21:271-8.] [Kronman et al. BMJ Qual Saf 2012;21:271-8.] Physicians who coped well Mixed-methods study 61 physicians who self-reported having made serious medical error Mean time since error was 8.1 years <10% had received prior training on disclosure More likely to have disclosed error (68.9% vs. 37.5%) No difference re lawsuit (21.3% vs. 15.5%) More likely to agree with statement My experience of coping with a medical error has made me a wiser person [Plews-Ogan et al. Acad Med 2016;91:233-41.] [Plews-Ogan et al. Acad Med 2016;91:233-41.] 10
From shame and blame What helps physicians? To a just culture. Being able to talk about it Disclosure and apology Forgiveness Dealing with imperfection Improving teamwork Teaching others about their experience [Plews-Ogan et al. Acad Med 2016;91:233-41.] Surgeons suggested that having an understanding of others reactions to adverse events may normalise their own reactions. In particular, recognising the similarities and differences among such reactions may ease an individual s own recovery process. [Luu et al. Med Educ 2012;46:1179-88.] 73% usually discuss mistakes with others to review clinical decision (91%) for others to learn from mistake (80%) to receive support (79%) 8% of faculty and 13% of residents did not know at least one colleague who would be supportive listener [Kaldjian et al. J Med Ethics 2008;34:717-22.] 11
Errors in judgment must occur in the practice of an art which consists largely in balancing probabilities. How can we do better? Sir William Osler, Aequanimitas (1928) Learning objectives 1. Describe the key elements in the initial disclosure of a harmful patient safety incident 2. Consider strategies to evaluate disclosure-related competencies 3. Identify the needs of the resident as second victim in the disclosure process Help us improve. Your input matters. Download the ICRE App, Visit the evaluation area in the Main Lobby, near Registration, or Go to: http://www.royalcollege.ca/icreevaluations to complete the session evaluation. Aidez-nous à nous améliorer. Votre opinion compte! Téléchargez l application de la CIFR Visitez la zone d évaluation dans le hall principal, près du comptoir d inscription, ou Visitez le http://www.collegeroyal.ca/evaluationscifr afin de remplir une évaluation de la séance. You could be entered to win 1 of 3 $100 gift cards. Vous courrez la chance de gagner l un des trois chèques-cadeaux d une valeur de 100. 12