Presentation is loading. Please wait.

Presentation is loading. Please wait.

Disclosure training Adverse patient events

Published byPaul Christophersen Modified over 5 years ago

Similar presentations

Presentation on theme: "Disclosure training Adverse patient events"— Presentation transcript:

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

2 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

3 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

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

5

6 SSM Health Online Event Reporting
Click on Report an Event Portal: 

7 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

8 Disclosure is a Communication Procedure!
Bad News Adverse Event

9 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:

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

11 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…..

12 Event Disclosure Role Play…
Observer Patient Physician

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

Download ppt "Disclosure training Adverse patient events"

Similar presentations

Managing a clinical incident

Managing a clinical incident
Critical Event Review (Root Cause Analysis)

Critical Event Review (Root Cause Analysis)
Giving Bad News Is an important communication skill Is a complex communication task which includes:- responding to patients emotional reactions Involving.

Giving Bad News Is an important communication skill Is a complex communication task which includes:- responding to patients emotional reactions Involving.
Dr P Henn 31.01.2011. Your words remembered for years The SPIKES model Developed by oncologists as a structure to break the news of life limiting disease.

Dr P Henn Your words remembered for years The SPIKES model Developed by oncologists as a structure to break the news of life limiting disease.
Prevention & Disclosure of Medical Error Dr. Ramadan Ibrahim Director Health Regulation Department Dubai Health Authority.

Prevention & Disclosure of Medical Error Dr. Ramadan Ibrahim Director Health Regulation Department Dubai Health Authority.
Patient Safety What is it? Why is it important? What are we doing? What is my part to play?

Patient Safety What is it? Why is it important? What are we doing? What is my part to play?
An Introduction to Patient Safety

An Introduction to Patient Safety
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 8 Engaging with patients and carers. LEARNING OBJECTIVE Understand the ways in which patients and carers can be involved as partners in health care.
Canadian Disclosure Guidelines. Disclosure - Background Process began: May 2006 Background research and document prepared First working draft created.

Canadian Disclosure Guidelines. Disclosure - Background Process began: May 2006 Background research and document prepared First working draft created.
Disclosing Adverse Events to Patients and Families March 16, 2010 Albert W. Wu, MD, MPH Johns Hopkins Bloomberg School of Public Health.

Disclosing Adverse Events to Patients and Families March 16, 2010 Albert W. Wu, MD, MPH Johns Hopkins Bloomberg School of Public Health.
Disclosure/Communication of Laboratory Errors Raouf E Nakhleh, MD Mayo Clinic Florida.

Disclosure/Communication of Laboratory Errors Raouf E Nakhleh, MD Mayo Clinic Florida.
New York Medical College Department of Family Medicine1 Patient Safety and Medical Errors Family Medicine Clerkship New York Medical College 2003 – 2004.

New York Medical College Department of Family Medicine1 Patient Safety and Medical Errors Family Medicine Clerkship New York Medical College 2003 – 2004.
Thomas H. Gallagher, MD University of Washington.

Thomas H. Gallagher, MD University of Washington.
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.

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.
© 2008 The Board of Trustees of the University of Illinois Collaborative Learning From Patient Safety: Presentation From PSOs and International Patient.

© 2008 The Board of Trustees of the University of Illinois Collaborative Learning From Patient Safety: Presentation From PSOs and International Patient.
Would You Like Swiss Cheese on That? Preventing Adverse Events in the Medication System.

Would You Like Swiss Cheese on That? Preventing Adverse Events in the Medication System.
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.

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

Adverse Drug Event Reporting
Preventing Surgical Complications Prevent Harm from High Alert Medication- Anticoagulants in Primary Care Insert Date here Presenter:

Preventing Surgical Complications Prevent Harm from High Alert Medication- Anticoagulants in Primary Care Insert Date here Presenter:

Similar presentations

Ads by Google