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

2. Qualities of an Effective Resolution
Economical
Ethical
Legal
Psychologically healing

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. “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

10. 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

11. 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

12. 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

13. 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

14. Questions?
Contact Information: Kira Hudson St. Vincent Indianapolis Risk Manager