1. Ethics Committees and Medical Error Carol Bayley, PhD July 6, 2011 Ethics Champions Program

2. Phone Etiquette Press * 6 to mute; Press # 6 to unmute Keep your phone on mute unless you are dialoging with the presenter Never place phone on hold

3. Overview What kind of problem is medical error? What do values have to do with it? What does the Ethics Committee have to do with this issue?

4. What kind of problem is it?

5. 1999 IOM study: Leading cause of preventable deaths 44—98,000 people die annually One million people injured annually Annual cost $17—29 billion

6. What does it look like? Medication errors (wrong drug, wrong patient, wrong dose, etc.) Wrong site surgery Equipment failure Inadequate skill “an accident waiting to happen”

7. Near Misses Harmless Hits Errors That Cause Harm ? Universe of Mistakes

8. Combined errors Overlapping Responsibilities staffMD

9. Two Approaches Pre-IOM report New Thinking Joint Commission Congressional action on mandated reporting Med-Mal insurers In our systems, values based

10. Old: Blame, Shame, Lie, Deny Deny the allegation; make the family or patient litigate to get information; don’t pay a penny that a court doesn’t require. Lie if necessary, and certainly if the truth won’t bring the person back and others won’t find out. Privately, identify the clinician (who gave the dose, ran the machine, did the surgery) and fire her. This will show the family “something was done” and will make an example for others to learn from.

11. New: Get to the bottom of it Swiss cheese model Person who “did it” is the last link in a causal chain Blame and shame shuts people up; if you discourage people from reporting, you will never improve

12. Swiss Cheese (Jim Reason)

13. Underpinning of policies In a values-driven organization, the values should link to behavior “Ethics is the application of values to action”

14. CHW Example Dignity Collaboration Justice Stewardship Excellence

15. Dignity Everyone we touch--patients, family members, physicians, other health care workers and our own CHW team members--possesses an inborn dignity as a person worthy of respect. Honest and direct communication Prompt supply of information Advice about legal system Honest admission Everyone is different Timely and sincere apology

16. Collaboration: Working together with physicians and other team members is at the heart of our service to patients. We are successful because of the work of an entire team. Atmosphere of trust, honesty, transparency No blame Work together to solve problems Relationship with system services for Risk Management, Legal, Care Management and Mission Integration

17. Justice: We treat everyone fairly and equitably regardless of rank or status. Well-educated or not, English-speaking or not, confident in the healthcare system or not, all are deserving of fair treatment. We take our fair share of the burden of claims, and expect the same of partners. Primary care physicians, specialists, “friends of the hospital” and infrequent admitters. Physicians and nurses treated equitably. We honor public accountability and rules for reporting error.

18. Stewardship: We hold precious assets of CHW: our human resources, our finances, and the trust the public places in us. We fairly compensate an injured party, even when that means expenditure of CHW funds. We share the burden of claims fairly with those that bear responsibility for them. We explore every avenue for a just settlement.

19. Excellence: Always doing better involves admitting that we are not quite “there.” With humility and determination we seek to constantly improve the systems we have so that they will not injure patients, families or caregivers. We share information to improve safety. We share claims information to study causes of our failures. We structure opportunities for improvement.

20. What can your ethics committee do? Informed consent education Review policies with organizational values in mind Help organization see that policies reveal ethical stance of organization