11/27, 12/2, 12/9 Error Disclosure, High Reliability in Medical Care, Second victim

Explain how disclosure of a harmful error is good for both patients and organizations

Good for patients

Good for Organizations

Patients expect their providers and health care organizations to be truthful and to provide open communication   Health Care providers are ethically obligated to minimize the suffering of patients  Failure to disclose an adverse event can further increase harm  Disclosure communication can also be viewed as an extension of the informed consent process  Disclosure promotes autonomy and engagement in making future health care choices

Transparent and timely communication with patients (particularly when an AE occurs) is reinforced in many state laws and hospital policies and by accrediting agencies like the Joint Commission   Disclosure , communication, and transparency may lead to possibly reductions in legal liability

Recognize best practices in disclosing a harmful error to a patient 

1. Disclosure is a safe practice expectation! 

   1. Many orgs have implemented fill disclosure programs that include provider/caregiver who acknowledges the error, takes responsibility and apologizes  

   2. Communication and resolution program (CRP) 

      1. Includes formal process for:  

         1. Disclosing unanticipated outcomes (including who should do the disclosing) 

         2. Reporting events to those responsible for patient safety, including external organizations  

         3. Identifying and mitigating risks and hazards  

2. In committing a disclosure, the provider/administrator should convey"  

   1. The facts  

   2. An expression of regret for the outcome  

   3. A commitment to investigate with feedback on the results 

   4. Available resources  

   5. Sincere apology  

3. The disclosure should be empathetic and timely 

Identify barriers to disclosure 

1. Patients fail to receive a full and truthful explanation when bad outcomes occur  

2. Healthcare workers' uncertainty about what to say to patients, what events to disclose, and the process for doing so  

3. Inexperience with disclosure process 

4. Limited training in communication skills 

5. Concern for negative patient reaction 

6. Concerns for malpractice liability, professional discipline, and professional reputation (deny and defend approach) 

7. Insufficient institutional support, including a negative organizational culture  

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Define the term “second victim”

• Healthcare providers

• Unanticipated adverse patient events, in a medical error and/or a patient-related injury

• Traumatized by the event

Explain the advantages and disadvantages of the term “second victims”

Advantage	Disadvantage
The term acknowledges the trauma that clinicians experience Shock value of victim draws attention to the issue That’s what we’ve been calling it all along	The emotional devastation of the clinician is much less significant than what is experienced by the pt Victim implies helplessness Victim implies the blamelessness of the clinician

Explain what occurs within each of the three phases of the Transactional Model and the

three long-term outcomes

Phase 1	Appraising the situationi experiencing the trauma
Phase 2	Restoring integrity  Constructive actions support personal growth and healing
Phase 3	Continuing professional life 1)Leave profession 2)Survive in their role 3)Thrive

Recognize physical and psychosocial stress responses of the “second victim”

Categorize coping strategies as destructive or

constructive

Categorize coping strategies as emotion-focused or problem-focused

List and briefly explain the 5 rights of “second victims”

1. Treatment that is just 

2. Respect

3. Understanding and compassion

4. Supportive care

5. Transparency and the opportunity to contribute to learning

Define “high reliability organization”

Organizations in which accidents rarely occur despite the error prone nature of the wprk

List and describe the five principles of high reliability and be able to recognize their

presence (or absence) in a given scenario

1. Preoccupation with failure

2. Reluctance to simplify

   1. Avoids the tendency to minimize problems 

3. Sensitivity to operations

   1. Awareness of how components of work fit together and awareness of ones own work operations to detect small errors 

4. Resilience

   1. Developing the capability to cope with or improvide responses to unexpected events 

5. Deference to expertise 

Recognize the presence (or absence) of characteristics that are consistent with a high

reliability organization in a given scenario

1. Closed to external environment 

2. Singular and Simple

3. Society is intolerant of catastrophic consequences

4. High degree of risk

5. Complex process

6. High organizational redundancy 

7. Simultaneous Loose Tight Operational Control 

   1. Flexible delegation of authority with high degree of individual accountability 

8. High professional diversity 

9. High organizational learning  

10. High organizational mindfulness

Describe challenges the health care system encounters on their journey towards high

reliability

1. Variability

2. Costs

3. Stakeholder needs

4. Presentation of Medical Harm

5. Fragmented system

6. Persistence of hierarchy

7. Less sensitivity to human factors