Communication Surrounding Adverse Events: A Simulation Education Program for Resident Physicians, Washington, DC 1
Investigators Laura J. Sigman, MD, JD, FAAP Dr. Sigman is a physician and manages legal and policy issues in the Emergency Department at Children s National in Washington, DC. She previously served as a Risk Manager and is currently working with the Legal and Ombudsmen offices on efforts to improve the grievance and disclosure processes throughout the hospital. She is a member of the AAP Committee on Medical Liability and Risk Management and teaches frequently on legal and risk management issues affecting clinicians and patients including communication around medical errors and adverse events. Angela T. Wratney MD, MHSc, FAAP, CHSE Dr. Wratney is an Attending in the Department of Critical Care Medicine at Children s National in Washington, DC. She is a Service Excellence Coach and has conducted interprofessional simulation sessions for over 8 years. Dr. Wratney especially enjoys her academic work in interprofessional team training with nurses, residents, pharmacists, social workers, and standardized parents supporting family presence in the ICU setting, communication around error disclosure, difficult airway escalation, and team debriefing. 2
Problem Statement Physicians find it difficult to handle conflict surrounding adverse events and disclosure of medical errors with families. They receive little training in communication and conflict management. How can we better educate physicians to communicate around medical mistakes, adverse events, and in situations of conflict in order to improve patients and families experiences and reduce dissatisfaction and legal claims? 3
Background Simulation exercises enhance physicians skills and comfort in dealing with challenging situations. Providing a safe venue for pediatric residents to practice with a panel of trained experts helps to improve their communication skills and enhance their abilities to effectively participate in a multidisciplinary team providing family-centered care. This work draws on programs and toolkits developed by the Agency for Healthcare Research and Quality and the Solutions for Patient Safety. The American Academy of Pediatrics also advocates for improved communication and disclosure of adverse events. 4
Process Description 5 Our project expanded on previous ombudsmen-led sessions for residents to improve communication skills and reduce conflict. We utilized simulation of an adverse event and an interprofessional panel of medical faculty, social workers, and ombudsmen in educational sessions. The sessions provided pediatric residents with an opportunity to learn processes for managing adverse events, practice communication skills with role-playing families, and receive feedback from experienced observers in handling adverse events and conflict in medicine.
Learning Objectives By the end of the session, participants will: Develop a systematic approach to adverse event disclosure Establish goals for communication around adverse events Demonstrate empathic delivery in adverse event disclosure Manage the resident role and apply best practices in interactions around adverse events Identify resources available when adverse events occur 6
Methods 7 We performed an extensive literature review of error disclosure, publications of best practice from national medical societies, and of the Society for Patient Solutions (SPS) and Agency for Healthcare Research and Quality (AHRQ) toolkits. A quarterly curriculum was reviewed and accepted by the Pediatric Chief Residents and the Curriculum Educational Committee. Each session includes didactic overview, video, small group resident-led conversation with a standardized parent and nurse facilitated by an expert from the panel. Large group debriefing focused on best practices in communication, conflict reduction, escalation and error disclosure.
Results 32 residents participated in 2 sessions delivered quarterly beginning June 2017. 7 Panel members participated and provided expert guidance and feedback on adverse event disclosure and on resident-led disclosure conversations. Social workers (3); Ombudsman (2); Physician faculty (2). Overall satisfaction with the course was 4.2 (max scale 5). Most participants reported baseline level of knowledge as very uncomfortable speaking with families about conflict or knowledge of legal issues. Panelists noted residents had excellent baseline communication skills in empathic listening, body language, and delivering appropriate apologies. 8
Results Continued Most residents reported not knowing that risk and error system reports should not be mentioned to the family nor included in the medical record. Many residents reported value in learning how to say appropriately say I m sorry without putting themselves or the hospital at risk. Residents appreciated learning how to incorporate the ombudsman and social work team members, and wanted more opportunities to practice medical-legal communication. 9
Key Lessons Learned 10 Residents are often uncomfortable in their communication skills when discussing adverse events in healthcare with families. Using an interprofessional panel of experts including social workers, ombudsmen, and physician faculty simulates the resources available to residents in clinical care and provides a safe forum for practicing communication skills and reinforcing good communication techniques. There is a greater need for this type of training in their educational curriculum.
Methodology for Further Implementation and Adoption The training sessions will be conducted quarterly Engaging the residency Director and Chiefs and the resident Curriculum Education Committee has led to a commitment to provide this training for residents as part of their ACGME curriculum. A didactic and question/answer session has been added to allow residents to explore their questions regarding risk management and legal issues in medical practice. This has been well-received. 11
References 12 AAP. Disclosure of Adverse Events in Pediatrics. Committee on Medical Liability and Risk Management and Council on Quality Improvement and Patient Safety. Pediatrics 2016;138. AHRQ. Communication and Optimal Resolutionhttps://www.ahrq.gov/professionals/quality-patient-safety/patient-safetyresources/resources/candor/index.html Gallagher, T, et al. Disclosing Harmful Medical Errors to Patients. N Engl J Med 2007;356:2713-9. Gallagher TH, Denham CR, Leape LL, et al. Disclosing unanticipated outcomes to patients: the art and practice.j Patient Saf 2007;3:158. Hickson et al. Identifying and addressing communication failures as a means of reducing unnecessary malpractice claims. N Carolina Med J 2007;68(5): 362-364. Raper, S, et al. Simulated Disclosure of a Medical Error by Residents: Development of a Course in Specific Communication Skills. Journal of Surgical Education 2014;71(6):e116-126. November/December 2014. Singh, V, et al. Disclosure and documentation of reported unanticipated medical events or outcomes: Need for healthcare provider education. Journal of Healthcare Risk Management 2012;32(1):14-22. Straumanis, J. Disclosure of medical error: Is it worth the risk? Pediatric Critical Care Medicine 2007; 8(2):S38-S43. Stroud L, McIlroy J, Levinson W. Skills of internal medicine residents in disclosing medical errors: a study using standardized patients. Acad Med 2009;84:1803-1808. Sukalich, S, et al. Teaching Medical Error Disclosure to Residents Using Patient-Centered Simulation Training. Acad Med. 2014;89:136 143.