Disclosure of Medical Errors AND Risk Management

Slides:

Advertisements

Similar presentations

Managing a clinical incident

Advertisements

Medical Errors and Apologies: Making the Case to a Physician Audience Angelo P. Giardino, MD, PhD, MPH.

Prevention & Disclosure of Medical Error Dr. Ramadan Ibrahim Director Health Regulation Department Dubai Health Authority.

PATIENT SAFETY Justin MFIZI Patient Safety officer KFH.

End of Life Care Education

Topic 8 Engaging with patients and carers. LEARNING OBJECTIVE Understand the ways in which patients and carers can be involved as partners in health care.

Accident Investigation for Supervisors

Medical Errors Frances Symons PHE 570. Definition- Medical Error Failure of a planned action to be completed as intended or the use of a wrong plan to.

Disclosure and Resolution Programs Exciting Developments, Challenging Barriers Thomas H. Gallagher, MD Professor of Medicine, Bioethics & Humanities University.

Canadian Disclosure Guidelines. Disclosure - Background Process began: May 2006 Background research and document prepared First working draft created.

APOLOGISING FOR MEDICAL NEGLIGENCE The role of apology in Open Disclosure Professor Prue Vines, UNSW Law.

Being Open Suzette Woodward Director of Patient Safety Strategy NPSA July 2008.

Disclosing Adverse Events to Patients and Families March 16, 2010 Albert W. Wu, MD, MPH Johns Hopkins Bloomberg School of Public Health.

Medical PROFESSIONALISM in the next millennium ABIM foundation ACP foundation European Federation of IM.

The Sorry Works! Coalition. Quotables “I would never introduce a doctor’s apology in court. It is my job to make a doctor look bad in front of a jury,

ESRD Network 6 5 Diamond Patient Safety Program

Medical Malpractice: A Physician’s Perspective Kevin Biese, MD March 5 th, 2007.

Tragedy Strikes – what next? Setting Up a Successful Patient Disclosure Program Timothy B McDonald, MD JD Professor, Anesthesiology and Pediatrics University.

Healthcare Errors Error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. By IOM.

Human Factors & Patient Safety

DR NIRANJAN P DR K LAKSHMAN DR M S SRIDHAR AUDIT ON DISCHARGE SUMMARIES.

Ethical encounter with errors of laboratory and colleagues

Topic 5 Understanding and learning from error. LEARNING OBJECTIVE Understand the nature of error and how health care can learn from error to improve patient.

What do patients and families need to know when errors occur? Susan Moffatt-Bruce MD, PhD, FACS, FRCS(C) Chief Quality and Patient Safety Officer Associate.

1 Disclosures © HIPAA Pros 2002 All rights reserved.

Leading a Patient Safety Program Madeleine Biondolillo, MD Massachusetts Department of Public Health Gordon Schiff, MD Brigham & Women’s Hospital; Harvard.

QSEN Primer Or, “QSEN in a Nutshell” 1.  1999—Institute of Medicine published “To Err is Human”  Determined errors have an effect on both patient satisfaction.

Topic 10 Patient safety and invasive procedures. Learning objective The objective of this topic is to understand the main causes of adverse events in.

Topic 8 Engaging with patients and carers. Learning objective Understand the ways in which patients and carers can be involved as partners in health care.

Topic 6 Understanding and managing clinical risk.

RISK MANAGEMENT OVERVIEW 2014 Louise E. Swensen, JD, MS, CPHRM Associate Director.

SAYING SORRY IN CLINICAL PRACTICE R. Gyaneshwar Combined UOF/Sathya Sai Service Organisations Fiji Medical Seminar August 16, 2009.

Component 2: The Culture of Health Care Unit 9: Sociotechnical Aspects: Clinicians and Technology Lecture 1 This material was developed by Oregon Health.

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 10Safety Concerns in Healthcare.

ADMINISTRATION SERIES: MEDICAL ERROR Jay Green Dr. Lisa Campfens March 11, 2010.

“Never Events”: Will They (N)Ever Go Away? Maryland Association for Healthcare Quality October 29, 2009 Health Science Institute Larry L. Smith Vice President,

Topic 10 Patient safety and invasive procedures. LEARNING OBJECTIVE The objective of this topic is to understand the main causes of adverse events in.

ETHICAL AND LEGAL CONSIDERATIONS. KEY TERMS- DEFINE  Battery  Ethics  Malpractice  Negligence  Risk management  Safety committee  Standard of care.

Disclosing Medical Errors: 2008 and Beyond Wendy Levinson, MD Professor of Medicine University of Toronto.

Medical Accidents in Women’s Healthcare: the Patient’s Perspective PETER WALSH, CEO,

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Ch 6 Defenses to Liability Suits.

Investigational Devices and Humanitarian Use Devices June 2007.

JCAHO Patient Safety. Background 1999 Institute of Medicine report: “To Err is Human: Building a Safer Health System”  Estimated 44,000 – 98,000 medical.

Preventing Errors in Medicine

The Role of Risk Management in Patient Safety

Disclosure of Unanticipated Outcomes

Part C: Section C.3 1 Part C: Managing Emotions After Difficult Patient Care Experiences Integrating a Difficult Patient Care Experience.

ISBN: Chapter 1 Health Care Delivery for the 21 st Century.

Content from National Patient Safety Agency material 2 Day Lead Investigator.

Open Disclosure Communication with Patient/ Family following adverse events.

RISK MANAGEMENT Kansas Spine & Specialty Hospital Annual Competency 2016.

1 Module 4 Learning From When Things Go Wrong A Resource to Support Training Activity in Clinical Settings.

Being open Communicating with patients and carers after patient safety incidents.

Excellence in specialist and community healthcare Duty of Candour Sal Maughan, Head of Risk Management.

HEALTH CARE RISK MANAGEMENT Suzette Goucher, J.D., R.N.

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

© 2016 McGraw-Hill Education. All rights reserved. Ch 6 Defenses to Liability Suits.

Clinical risk management Open Disclosure. Controlling Unpredictability of health Laws Civil law Parliamentary law & statues Client rights Professional.

Patient Safety Take a little time to read through these slides, where a question is asked stop and consider it for a few moments before going on to the.

Disclosing and Resolving Adverse Outcomes

Geriatrics Curriculum to Model Characteristics of the

HIPAA Pros - Disclosures

Patient and Families Following Medical Harm

When Things Go Wrong: Disclosure of Medical Error

Disclosure training Adverse patient events

Event & Disclosure Reporting

Why should we disclose? Patients have the Right to Know

Karien Uys, M.Soc.S, BNS, RN, CQI&PS. The Journey Continues.

Rita Simmons Sr. Director, Operations Risk Management.

Second Victim-Peer Support Team

Presentation transcript:

Disclosure of Medical Errors AND Risk Management

No one makes an error on purpose Everyone makes mistakes every day No one admits an error if you punish them for it.

“Cushing openly acknowledged and described significant instances of human error, mistakes in judgment and technique, and equipment and supply oversights, regardless of whether these events affected patient outcome.”

Iceberg Model of Accidents and Errors

Institute of Medicine: “To Err is Human” 98,000 deaths/year 0.2-2% hospitalized patients experience major permanent injury or death secondary to medical care Vast majority (90%) due to failed systems and procedures, not physician negligence System flaws set good people up to fail

Humans Make Errors However most errors are systems related! Limited short term memory Being late or in a hurry Limited ability to multi-task Fatigue Stress Interruptions Environment However most errors are systems related! Interaction of multiple factors at different levels of a complex system

Adverse event: harm related to medical treatment or lack thereof and generally not caused by an error Medical errors can have a subjective component Patient’s perspective may be very different than physicians

NEJM 354:21, 2006 “Malpractice suits often result when an unexpected adverse outcome is met with a lack of empathy from physicians and a withholding of essential information” Health care providers often do not disclose medical errors for fear of lawsuits

University of Michigan Health System Medical Error Disclosure Program with Compensation resulted in fewer claims and lawsuits with lower litigation costs.

Disclosure of Adverse Events National Patient Safety Foundation (2000) “when a healthcare injury occurs, the patient and the family or representative is entitled to a prompt explanation of how the injury occurred and it’s short and long-term effects. When an error contributed to the injury, the patient and the family should receive a truthful and compassionate explanation about the error and the remedies available to the patient. They should be informed that the factors involved in the injury will be investigated so that steps can be taken to reduce the likelihood of similar injury to other patients.”

Disclosure of Adverse Events Emotional effects for patient and physician make communication difficult Communication failures may cause distrust of medical team Communication should be prompt, compassionate and honest Error disclosure may reduce a patient’s intention to file a lawsuit

What If…I Make a Mistake Don’t panic, stay calm Perform appropriate clinical action to stabilize situation – ask for help if needed Contact senior residents and/or attending Hospital risk management In advance, plan what should be said to patient/family and by whom

Provide information on what happened Provide apology and expressions of regret Concern, caring, empathy Patient’s value an acknowledgment of responsibility Emphasize individual and system level changes so that recurrences are prevented for other patients

Summary Disclosure now viewed as responsibility of healthcare team Communication may be difficult but should be prompt and compassionate Emphasize system and personal improvements to avoid similar event Appropriate and timely disclosure may not increase malpractice lawsuit risk