IHI PS 105 - Responding to Adverse Events

When giving an explanation for why an event happened, it is always important to:

Be factual. Explanations may mitigate or aggravate the patient's feelings about an event, but they should be factual. Although you may sometimes want to discuss things with the risk management department or bring documents, these actions are not always needed or appropriate.

Your organization has a voluntary reporting system for errors. Which of the following incidents should you report?

Both of the incidents above The best answer is both of the incidents. When people report errors, whether they have negative consequences or not, organizations can learn from them. It is your job to report the errors you experience, and the organization's job to decide which ones are the highest priority for action.

When an error occurs, which of the following is generally the proper order of prioritization?

Care for the patient, communicate with the patient, report to all appropriate parties, check the medical record. The first priority is to address the current health care needs of the patient. After caring for the patient's immediate clinical needs, start preparing for the initial communication session with the patient and/or the patient's representative. Various people, departments, entities, or agencies may need to be notified that there has been an adverse event, so once the immediate patient needs are addressed, you'll want to make sure the proper parties are informed. The last concern is making sure the medical record contains a complete, accurate record of the clinical information pertaining to the unanticipated adverse outcome.

According to a study by Scott and colleagues, what is a common type of support caregivers ask for after adverse events?

Early identification of suffering This research revealed that caregivers involved in adverse events, or "second victims," ask for the following support: early identification of suffering, provision of ongoing emotional support from peers, coordination of the institution's overall event response to include gossip control, and an invitation to become a member of the event-related improvement team.

Which of the following is true regarding communication about adverse events with patients?

In some cases, the care team may decide for medical reasons to defer communication with a patient about an upsetting incident. Patients have a right to know what happened in their care, and not having all the facts is not a reason to delay communication; just share what you know. Training in communication is helpful, but communicating after an adverse event is not unduly complex, and it should be done by those directly involved in the incident.

If you are responsible for the initial communication with a patient about an error, which of the following should you be sure to do?

Let the patient and family know who is available to help them. It is important to acknowledge that the event occurred and to make it clear who will be available to help the patient and family. You probably don't know exactly what caused the error at the time of the initial communication, but that's OK. Rather than completely disguising your feelings, you should express empathy and compassion.

Which of the following statements about apologizing after a medical error is always true:

None of the above The best answer is "none of the above" because every institution is different and will have different policies and preferences. Some institutions may see apologizing as a risky endeavor because it may be construed as an admission of guilt and have legal ramifications (despite mounting evidence to the contrary). In these cases, clinicians should discuss apologizing to the patient with the risk management department, and use their best judgment about how to proceed.

As the Health Unit Coordinator (HUC), it is your job to enter orders from providers into the computer system. You check charts every couple of hours for new orders, unless the providers "flag" the chart by turning a dial on its side to red — in which case, you check the chart right away. On a particularly busy day, you see a chart tucked in a corner and realize that you have not looked at it in at least six hours. Worse, you check the order dial and see that it's partly red. On the order sheet are orders for "STAT" pain medications and antibiotics for a new patient. You quickly input the orders, your heart pounding. Three hours later, the patient is transferred to the intensive care unit with worsening sepsis (infection). Why is it important for the organization to offer you help and support at this time?

Offering support helps prevent depression or decreased job satisfaction. There is evidence that the providers involved even in minor errors and near misses can suffer from feelings of shame, depression, and guilt. Sometimes they can be unable to continue their work. Even if the organization has no legal obligation to provide help for providers involved in adverse events, doing so may prevent these negative consequences.

When an adverse event befalls a patient, who are the "second victims" according to Dr. Albert Wu?

The caregivers involved in the error The term "second victim," coined by Dr. Albert Wu, highlights the devastation that caregivers can suffer when they are involved in a medical error, as well as their need for support from colleagues and their institution. After an adverse event, the caregivers involved may feel upset, guilty, self-critical, depressed, and scared. In addition, their job satisfaction, ability to sleep, relationships with colleagues, and self-worth can be negatively affected.

Which of the following is the best explanation for why caregivers involved in medical errors are "second victims" according to Dr. Albert Wu?

They experience their own trauma. Caregivers involved in medical errors are referred to as "second victims" because they can experience their own trauma. The term "second victim," coined by Dr. Albert Wu, highlights the devastation that caregivers can suffer when they are involved in a medical error, as well as their need for support from colleagues and their institution.

According to researchers, which of the following is a common reason why caregivers choose not to communicate when something bad happens?

They fear disapproval. In the paper discussed in this lesson, published by Banja and colleagues, there were many reasons why providers found it challenging to communicate with patients and families after adverse events, many of which related to fear — fear of disapproval, fear of job loss, fear of anger from the patient, fear of lawsuits, etc. Providers did not discuss lacking empathy for patients and families or feeling that the harm was not their fault.

Janice is a nurse on the orthopedics unit. This night, she is caring for five patients, as well Janice is a nurse on the orthopedics unit. This night, she is caring for five patients, as well as a new admission from the emergency department. While juggling patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who is in significant pain from a fractured hip. Janice hastily writes down the morphine order from the resident and is then called away when another patient falls out of bed. An hour later, she realizes, to her dismay, that she has not yet given Mrs. Bernardo her pain medication. When she rushes into the room, the patient is crying and asking, "Why won't someone help me?" Janice quickly administers the morphine. When discussing the event a little while later with Mrs. Bernardo, the most appropriate initial comment would be:

"How is your pain?" The first and most important issue when a patient receives less than ideal care is to make sure you stabilize and care for the patient. Only after the patient's safety and comfort are addressed should you consider an apology.

Janice is a nurse on the orthopedics unit. This night she is caring for five patients, as well as a new admission from the emergency department. While juggling patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who is in significant pain from a fractured hip. Janice hastily writes down the morphine order from the resident and is then called away when another patient falls out of bed. An hour later she realizes, to her dismay, that she has not yet given Mrs. Bernardo her pain medication. When she rushes into the room, the patient is crying and asking, "Why won't someone help me?" Janice quickly administers the morphine. Why is it important for Janice to apologize to Mrs. Bernardo for the delay in her pain medication?

A genuine apology could help Mrs. Bernardo recover from her trauma AND could help Nurse Janice feel better. A genuine apology helps both the patient and staff members deal with their emotional trauma. Although there was probably no permanent injury in this case, the patient certainly experienced more pain than necessary, and Nurse Janice felt dismayed by what happened.

When giving an explanation for why an adverse event happened, it can sometimes be a good idea to:

Say something like, "There is just no excuse for what happened." Sometimes the statement "There is no excuse for what happened," can be the most honest and dignified explanation at the time of your initial apology. Explanations may mitigate or aggravate the patient's feelings about an event, but they should be factual. The speaker must make it very clear that the patient did not do anything wrong.

Which of the following is a support mechanism that might be available to caregivers after traumatic events?

The Employee Assistance Program A variety of support systems may be available to the caregivers involved in a medical error, including the Employee Assistance Program (EAP), psychological counseling, the local medical society, or organizations such as Medically Induced Trauma Support Services.