Disclosure training Adverse patient events

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Presentation transcript:

Disclosure training Adverse patient events Julie K. Gammack, MD Matt Shorey, J.D.

Objectives Resident Education and Experience in Disclosure of Adverse Events All residents must receive training in how to disclose adverse events to patients and families. Residents should have the opportunity to participate in the disclosure of patient safety events, real or simulated

Adverse Events: WILL HAPPEN Unsafe Condition Functional equipment with broken part Procedure kit with missing pieces Near Miss (“Great Catch”) Order written on wrong patient (caught before carried out) Wrong medication dose prescribed (pharmacy adjusted) Medical Error Order written on wrong patient and carried out Wrong site procedure Known risk/side effect Ototoxicity with antibiotics Pneumothorax after thoracentesis Headache after lumbar puncture Unanticipated Outcome Allergic reaction Excessive bleeding after procedure Clinical deterioration despite optimal care

Spectrum of Adverse Events Retained Object Wrong Site Delayed foley catheter removal Harm Near Miss Late Lab Draw Unsafe Condition Frequency

SSM Health Online Event Reporting Click on Report an Event Portal: https://ssmeventreporting.secure.force.com/selectevent

What if an adverse event occurs…. Take care of the patient Inform your supervisor Inform your attending who will: Report to SLUCare and hospital risk management Develop a patient care action plan Determine medical provider contact for patient Disclose the event within 24 hours Document disclosure discussion

Disclosure is a Communication Procedure! Bad News Adverse Event

SPIKES 6-step approach STEP 1: SETTING UP the Interview right facts, right time, right people STEP 2: Assessing the Patient’s PERCEPTION what is known, what has been communicated STEP 3: Obtaining the Patient’s INVITATION STEP 4: Giving KNOWLEDGE and Information to the Patient STEP 5: Address and respond to the Patient’s EMOTIONS STEP 6: Strategy and Summary next steps, follow-up, further plans Baile WF, Buckman R, et al. SPIKES – A SixStep Protocol for Delivering Bad News. Oncologist 5:302-311. 2000

Role Play: Inconclusive biopsy specimen What were the positive SPIKE elements of the conversations? What were the negative elements of the conversation?

I’m Sorry….??? Express regret…..avoid blame… I’m sorry this happened to you… We’re sorry for what you are going through… I apologize for the difficulty that this has caused… We deeply regret that this event occurred….. We don’t want this to happen again and will be investigating how we can prevent this……. Dr. Jones made a mistake…. If only the nurse had done what I …… He didn’t do the right test…. It really isn’t my fault because….. We should have fixed this days ago…..

Event Disclosure Role Play… Observer Patient Physician

Wrap UP: What did you learn…. Take away points…..