Disclosing and Resolving Adverse Outcomes And Medical Errors Copyright © 2003-2013, Revised 2004, 2006, 2008, 2011, 2013 Speaker’s Notes

Qualities of an Effective Resolution Economical Ethical Legal Psychologically healing

Causes of “Unanticipated Outcomes” Uncorrected “unreasonable” expectations Biological variability Low probability risks & side effects Wrong judgments without negligence Individual, team or systems errors and equipment failures

Hindsight Bias Universal tendency Seeing events/choices as having been more predictable when looking backwards, after the outcome is known Examples? Speaker’s Notes

Unanticipated outcome Which Track? Care Unreasonable Care Reasonable System failure(s) Natural progression of medical condition Clinician performance/errors Inherent risk of investigations or treatments Unanticipated outcome Equipment malfunctions Harm not preventable Harm preventable

Medical / Systems Error “Act of commission or omission with potential consequences for the patient that would be judged wrong by skilled and knowledgeable peers at the time it occurred.” (Wu, 1997) Failure of a planned action to be completed as intended or the use of an incorrect plan to achieve an aim (IOM) Deviation from standard of care Speaker’s Notes

I Investigate to understand how this happened An AID to Disclosure A Acknowledge the disappointing event/outcome I Investigate to understand how this happened D Disclose an accurate explanation and pursue resolution

Contribution vs. Blame Which feels most fair and answerable by mature professionals? “How much do we believe _________ contributed to the adverse outcome?” vs. “Who is to blame for the adverse outcome?” Speaker’s Notes

“I’m so sorry that our actions have caused you harm.” Sympathy or Apology? Care Reasonable Express sympathy for their experience “I’m very sorry you and your family have had to endure so much pain this last week.” Apologize for causing harm “I’m so sorry that our actions have caused you harm.” Care Unreasonable

When Adverse Event Involves Another Clinician Who should be answering questions about the care provided? The clinician who provided it? A subsequently treating clinician? “It sounds like you have concerns about Dr. X’s treatment. Since he is in the best position to understand and describe his care, I encourage you to reach out to him with your questions and I will make him aware of your concerns.” Speaker’s Notes

Approach Shaped by Causation Care Reasonable Care Unreasonable ALEE Anticipate/Adjust Listen Empathize Explain ALEE + TEAM Truth, Transparency, and Teamwork Empathy Apology & Accountability Manage until resolved Unanticipated outcome

Approach Shaped by Causation Care Reasonable Care Unreasonable ALEE Anticipate/Adjust Listen Empathize Explain Document ALEED + TEAM Truth, Transparency, and Teamwork Empathy Apology & Accountability Manage until resolved Unanticipated outcome

Medical Records Open Communication Documentation All conversations should be documented in the medical record and should include the following information: 1) Date, time and location of the conversation 2) Attendees (and their relationship to patient) 3) Facts conveyed regarding patient's health status, additional care and treatment 4) Explanation offered 5) Agreed next steps 6) If transfer of care was discussed 7) Offers of assistance/good will (e.g., chaplain, social work, etc.) 8) Name of contact for further questions and concerns

Questions? Contact Information: Kira Hudson St. Vincent Indianapolis Risk Manager kshudson@stvincent.org