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

2. Outline  Introductory info  Error  Small group cases  AHS guidelines  Disclosure  Small group cases  Documentation/Law  Case discussion 10 min 30 min 10 min 20 min 5 min

3. Objectives  Understand models of error  Learn the steps in management of a severe adverse event  Understand the Alberta Health Services Disclosure of Harm Policy  Understand what types of events require disclosure  Learn how and what to disclose when error happens

4. Medical error stats 2004 HQCA Alberta Patient Safety Survey

6.  Results  N=1512  7.5% AE rate, higher in teaching hospitals 37% thought to be highly preventable 5% permanent disability, 16% death Medication safety, surgery top 2 areas

7. Adverse Event Harm Close Call Medical Error Canadian Disclosure Guidelines. Canadian Patient Safety Institute

8. Guiding Principles Autonomy Patient Centered Care Honesty Transparency Trust

9. Human Error Reason. Human error: models and management. BMJ 2000;320:768-70

10. Error prevention?

11. Small group cases #1  10 minutes  Cases 1 & 2

12. Management of Serious Adverse Events iweb.calgaryhealthregion.ca/qshi  Immediate management: RESPOND  Continuing management: ACE

14. Just & Trusting Culture

15. Safety Learning Report

18. Disclosure

19. Disclosure = ?

20. Disclosure: Underlying Principles Hickson, 1992; Beckman, 1994; Vincent, 1994; Kraman, 1999; Gallagher, 2003

21. What does it mean?

22. Why don’t we want to do it?

23. When do we do it? Close call No harm Minimal harm Moderate harm Severe harm Fatal harm Required Disclosure Discretionary Disclosure

24. Who does it?

25. How do we do it?  Immediate Acknowledgment  Initial Disclosure  Follow-up Disclosure  Final Disclosure Apology Listen EmpathizeOffer to explain AHS Procedures for Disclosing Harm to Patients Acknowledge

26. Apology  “Apology is not an ethical right, but a therapeutic necessity” – Lucian Leape

27. Small group cases #2  10-15 minutes  Cases 3, 4 & 5  “Confronted by an empathetic and apologetic physician, patients and families can be astonishingly forgiving.”  “Only then is it appropriate to approach the mistake with a problem solving focus”

28. Disclosure Tips  Set the tone  Timeliness  Privacy  Setting  Body language  Be in control, but not controlling  Simple, slow  Interactive  Avoid speculation  Describe next steps

29. AHS Procedures for Disclosing Harm to Patients

30. Canadian Medical Protective Association Information Sheet, March 2005

31. Case discussion

32. Take-home points  Adverse events are common  System approach to error  RESPOND to serious adverse events  Disclosure is mandatory when patients have suffered any level of harm  Disclosure is often a multi-step process

33. The END