1. UMMC Risky Business?

2. YES We work with YOU High Acuity Increasing Volume

3. Less Obvious Risks Complex vs Complicated Tightly Coupled Swiss Cheese Effect

4. Systems Problems Individuals have Good Intentions Systems Solutions are the Goal Not just at UMC - National Focus

5. Systems “Try Harder” – not the answer “Be more careful” – not the answer Change systems so that it is hard to do the wrong thing

6. In three months YOU will be the EXPERTS on what is broken in our system

7. University Hospital You write an order for a medication Medication arrives on unit Greater then 20 steps involved Each with several potential failure modes

8. What Can you Do To Decrease your Risk? Avoid Inappropriate Communications Preventable source of risk to all of us Product of anger, fatigue, & frustration (often valid) Avenue to vent in what has been felt to be a harmless manner

9. My Clever Note in the Chart will Prove I am Right! No longer Harmless; Stakes are High Nobody wins when chart jousting Harm for the individual writing the remark Harm for the target of the remark Harm to the medical center Plaintiff Attorneys Pal

10. Examples I Have Seen (in this medical center) “The nurses on this floor clearly don’t know how to take of the a (this type) patient.” “The (other service) is killing my patient.” “Admit to (unit). Do not assign to agency nurse as the agency nurses do not take good care of (this type) patient.”

11. Don’ t Let This Be YOU University has settled cases in the last few years where the medical care delivered to the patent was defensible, however, inappropriate remarks in the record required settlement.

12. What Can You Do? Don’t create additional risk by fighting in the medical record Learn and teach (!) a more effective means to communicate Consider the example you set Inflammatory remarks damage working relationships in an era when we need to pull together as a medical community Proper manner to correct errors in the record

13. Houston- We Have A Problem You will not plan nor intend to harm a patient Yet, along the way, SOMETHING WILL GO WRONG An adverse event WILL OCCUR

14. Bad News - What Next? Talk to your attending Talk to Risk Management Talk to the Patient / family The process of communicating information regarding the results of a diagnostic test, medical treatment, or surgical intervention is known as Disclosure

15. DISCLOSURE Disclosure is attending driven Remain calm / objective Truthful, compassionate explanation of FACTS Do not blame someone or imply causation Usually the entire truth is learned gradually Document appropriately

16. The Triad of Risk Management CommunicationDocumentation Patient Care

17. “I’m cutting you off.”