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Medical Errors: Avoiding Further Harm to Patients and Clinicians

Medical Errors: Avoiding Further Harm to Patients and Clinicians. Jo Shapiro, MD, FACS Director, Center for Professionalism and Peer Support Brigham and Women’s Hospital Associate Professor, Otolaryngology Harvard Medical School.

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Medical Errors: Avoiding Further Harm to Patients and Clinicians

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  1. Medical Errors:Avoiding Further Harm to Patients and Clinicians Jo Shapiro, MD, FACS Director, Center for Professionalism and Peer SupportBrigham and Women’s Hospital Associate Professor, OtolaryngologyHarvard Medical School

  2. Patients commonly spoke of feeling betrayed by clinicians they had previously trusted because, they said, their doctors had been unwilling to talk to them openly about what had occurred. … they expected an honest and “human” response. QualSaf Health Care 2004;13:3-5

  3. Making the case Doing the right thing Hardest task at time of maximum clinician and patient vulnerability Gap between pts and clinicians Requires skills and sometimes advice Support is crucial

  4. Reflection Think of a time when you were involved in a medical error that caused patient harm.

  5. What were some of your feelings?

  6. Emotional impact of errors on clinicians Sadness Shame Self-doubt Fear Anger Isolation

  7. Helmreich’s observations: Similarity between medicine and aviation “…[both stress] the need for perfection and a deep perception of personal invulnerability…” Helmreich, Davies. Culture, Threat and Error: Lessons From Aviation. Can J Anesth 2004; 51:6

  8. Emotional impact of errors on clinicians Sadness Shame Self-doubt Fear Anger Isolation

  9. Disclosure Impact Do we think that any of these emotions might have an effect on our discussions with patients and families?

  10. Disclosure Impact Do we think that any of these emotions might have an effect on our discussions with patients and families? How could they not?

  11. Potential impact on disclosure and apology • Denial and defensiveness • Jargon • Over-blaming (self or others) • Not listening or soliciting questions • Speculating 12

  12. Disclosure Coaching

  13. Brigham and Women’s Hospital • 793-bed tertiary care facility • Major teaching hospital for Harvard Medical School • Physician and scientist faculty: 2,738

  14. The Center's mission is to encourage a culture that values and promotes mutual respect, trustandteamwork.

  15. Teamwork Training Conflict Management Just Culture Initiative Professionalism Initiative • Peer Support • Disclosure Coaching Wellness

  16. Principles for transparent and compassionate disclosure and apology • Disclosure should be an opt-out process • If you decide not to disclose, it should be because it will be harmful to the patient and/or family • Get a second opinion • Could be paternalistic, i.e., not telling a patient they have cancer/bad news

  17. Disclosure principle: timing • Disclose as soon as you are aware of the AE, within reason. • Not during a code, but not 6 months later

  18. Who and when • Attending • Other healthcare team members: huddle • NOT house staff alone • As proximal to event as possible for first discussion

  19. How Empathy – find your sorry - Meg Gaines Identify your other emotions and then check them at the door Attention to medical/social needs Apologize for any known errors Allow for silence Ask for questions/concerns/emotions

  20. Sorry Failure of the English language

  21. When do we need to apologize?

  22. Naming adverse events leads to outcome bias and reinforces unhelpful cultural biases Errors Incidents Complications Mistakes Calamities Negligence Malpractice

  23. Terms • Adverse event: An undesired patient outcome, whether transient or permanent, caused by medical management rather than the underlying condition of the patient; it may or may not be related to an error • Error: The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim

  24. Only a few don’ts • Don’t speculate • Don’t hide things you know to be true • Don’t apologize for making an error if you aren’t sure you made one • Don’t use jargon • Don’t blame others

  25. Disclosure is a process, not an event Free to say we don’t know yet Explain process (not single event) – review will be ongoing Institutional efforts at future event prevention Follow up re clinical or social needs

  26. Emotional impact of errors on clinicians Sadness Shame Self-doubt Fear Anger Isolation

  27. But sometimes recovery is thwarted… Many times reactions are transient … causing harm to clinicians and their patients

  28. Error impact 3,171 MDs surveyed in US and Canada Waterman et al. JtComm J Qual Patient Saf. 2007 Aug;33(8).

  29. So, how do we facilitate coping and resilience after adverse events? Group peer support Sometimes an entire team is affected

  30. But physicians and clinicians at the sharp end of the error may have different needs…

  31. Hu J, Fix M, Hevelone N, Lipsitz S, Greenberg C, Weissman J, Shapiro J. JAMA Surg 2012 Attitudes and needs of physicians for emotional support: The case for peer support

  32. Barriers to seeking support • Lack of time (89%) • Stigma (77%) • Lack of confidentiality (79%) • Access (67%)

  33. Sources of support % % Percent (%) % 34

  34. Factors associated with resilience after adverse events Disclosure and apology Learning from the error/ understanding how to prevent recurrences Dealing with imperfection Talking about it with colleagues Forgiveness Sharing that learning with colleagues and trainees Plews-Ogan M, May N, Owens J, Ardelt M, Shapiro J, Bell SK. Wisdom in medicine: What helps physicians after a medical error. Acad Med. 2015 Sep 4.

  35. Peer support 1:1 peer support Group peer support

  36. Powerful impact on safety culture • Personal invulnerability human factors • Shame and blame promotes Just Culture • Expectation of emotional denial normalizes rxns • Solely personal responsibility systems issues • Isolation community/solidarity • Self care is selfish it’s important so that you can get back to doing what you do well Helps us show up with compassion for pt

  37. Communication & Resolution Programs (CRPs) • Transparent with patients regarding adverse events • What happened and why • Whether the event was preventable • How recurrences will be prevented • Proactively and promptly offer financial and non-financial resolution when adverse events were caused by unreasonable care

  38. Benefits of CRP Response

  39. CRP in action • Study at University of Illinois • CRP intervention  significant changes • # of incident reports nearly doubled • # of claims cut in half • Reduced legal fees and total costs per claim, settlement amounts, and self-insurance costs Lambert BL et al. Health Serv Res. 2016

  40. Cause for hope “we are not victims of that world, we are its co-creators. …source of awesome responsibility…and profound hope for change.” - Palmer, P. Let Your Life Speak, Jossey-Bass, San Francisco, CA, 2001.

  41. Thank you for listening and engaging

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