Communicating with patients and/or carers about patient safety incidents - GOLD Workshop

Content from National Patient Safety Agency material Aims To provide an overview of the Being open framework For participants to be able to put Being open in practice For participants to learn key skills that underpin effective communication with patients, their families and carers following a patient safety incident.

Content from National Patient Safety Agency material Session 1: Background to Being open

Content from National Patient Safety Agency material Key actions from NPSA Patient Safety Alert: (2009) 1.Local policy 2.Leadership 3.Responsibilities 4.Training and support 5.Visibility 6.Supporting patients

Content from National Patient Safety Agency material Being open Framework guidance (2009) Being open:- Policy Principles Process Patient issues Supporting staff Board leadership

Content from National Patient Safety Agency material NHS Constitution (2010) ‘The NHS also commits, when mistakes happen, to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively.’ (Page 11)

Content from National Patient Safety Agency material Contractual ‘duty of candour’ to drive a more open NHS culture 4 December, 2012 New rules to toughen transparency in NHS organisations and increase patient confidence have been announced following public consultation. The government will create regulations that require NHS England to include a contractual duty of openness in all commissioning contracts from April NHS organisations will be required to tell patients if their safety has been compromised, apologise, and ensure that lessons are learned to prevent them from being repeated. Although all NHS organisations are currently expected to be open about mistakes, there is no contractual duty to hold them to account when this does not happen. Duty of Candour

Content from National Patient Safety Agency material The benefits of Being open

Content from National Patient Safety Agency material Patient/carer testimony 1

Content from National Patient Safety Agency material Effects of patient safety incidents On patients and/or carers –What would be your feelings and concerns if the patient was a member of your family? –What three things do you think patients and/or carers involved in this type of incident would want most? On healthcare professionals –How would you feel if you had been one of the healthcare professionals involved? –What three things do you think healthcare teams involved in this type of incident would want most?

Content from National Patient Safety Agency material Patient/carer testimony 2

Content from National Patient Safety Agency material What patients want The English public want: –34% an apology or explanation –23% an enquiry into the causes –17% support in coping with the consequences Less important were: –11% financial compensation –6% disciplinary action Source: MORI survey commissioned for the ‘Making Amends’ report, DOH, 2002

Content from National Patient Safety Agency material What patients want A full apology and tangible support (Idema et al., 2008) Information on the nature, cause and prevention of errors and emotional support (Gallagher et al., 2003)

Content from National Patient Safety Agency material Being open and legal liability Mater Hospitals, Brisbane, Australia. Significant reduction in claims with savings of nearly $2 million AUD over four years Singapore: large academic hospital: no cases that proceeded to litigation for 2 years. Estimated savings of $500,000 SGD University of Michigan: full disclosure programme halved the number of pending lawsuits. Average annual saving of $US 2 million

Content from National Patient Safety Agency material Being open and legal liability ‘It is both natural and desirable for clinicians who have provided treatment which produces an adverse result, for whatever reason, to sympathise with the patient or patient’s relatives; to express sorrow or regret at the outcome and to apologise for shortcomings in treatment. It is most important to patients that they or their relatives receive a meaningful apology. We encourage this and stress that apologies do not constitute an admission of legal liability. In addition, it is not our policy to dispute any payment, under any scheme, solely on the grounds of such an apology.’ NHSLA ‘Apologies and explanations (2009)

Content from National Patient Safety Agency material Organisations supporting the Being open principles

Content from National Patient Safety Agency material Key elements of the Being open framework

Content from National Patient Safety Agency material Principles of Being open

Content from National Patient Safety Agency material Overview of Being open process

Content from National Patient Safety Agency material Grading of patient safety incidents to determine level of response

Content from National Patient Safety Agency material Key learning points - session 1 Being open is what patients, their families and carers want to happen when an incident occurs Organisations like the NHSLA, WRP, MDU, MPS, GMC, RCN and others all support Being open Offering an apology is not an admission of legal liability There are ten Being open principles The level of Being open response is determined by an initial assessment of the severity of patient harm

Content from National Patient Safety Agency material Session 2: Putting Being open into practice

Content from National Patient Safety Agency material Bill and the wrong prescription

Content from National Patient Safety Agency material Nick Oliver and the blood transfusion

Content from National Patient Safety Agency material Key learning points - session 2 Most patients want: o Acknowledgment that there has been an error o An apology (sincere, verbal and written) o An explanation o Information on what, if anything, can be done to repair the harm o Reassurance that, as far as possible, you will try to prevent recurrence Choose an appropriate lead; Consider being accompanied Establish a relationship Ask what people are feeling and need; Don’t assume Don’t be afraid to say you don’t know yet Offer and arrange a key contact

Content from National Patient Safety Agency material Session 3: Discussing the incident, outlining the next steps and completing the process

Content from National Patient Safety Agency material Bill and the wrong prescription

Content from National Patient Safety Agency material Tom Slater and the laryngectomy

Content from National Patient Safety Agency material Process completion Discuss findings of investigation and analysis Inform on continuity of care Share summary with relevant people Monitor how action plan is implemented Communicate learning with staff

Content from National Patient Safety Agency material Key learning points - session 3 Being open helps patients / carers deal with the effects of a patient safety incident Being open is a process, not a one off event Avoid making assumptions about what people are feeling and thinking. Ask; Use open ended questions Stick to the facts as they are known Document Being open discussions Speak to patients, families and carers as you would wish to be spoken to yourself, i.e. openly and honestly

Content from National Patient Safety Agency material Any questions? Further information can be found at: