What’s New in the
Patient Safety World
April 2018
· More
Support for Communication and Resolution Programs
· Joint
Commission and the Second Victim
· Anesthesia
in Parkinson’s
· Radiologists
Get Fatigued, Too
More Support for
Communication and Resolution Programs
Disclosure and
apology after an adverse medical event where errors contributed is not only the
right thing to do, it also likely results in lower liability costs. Our
numerous columns on the issue are listed below. Disclosure and apology has
evolved into “communication-and-resolution” programs. Such programs
communicate with patients when adverse events occur, investigate and explain
what happened and, where appropriate, apologize and proactively offer
compensation.
Our most recent
columns on the issue (our October 2017 What's New in the Patient Safety World
column “More
Support for Disclosure and Apology” and January 3, 2017 Patient Safety Tip of the Week “What’s
Happening to “I’m Sorry”?”)
discussed not only successes of such programs but also barriers to successful
implementation.
A new study further
demonstrates the success of communication and resolution programs (CRP).
LeCraw and colleagues compared liability outcomes
before and after collaborative communication resolution program implementation
at a health system in Tennessee (LeCraw
2018). 43% of events with injury from medical error were resolved
with apology alone. Compared to pre-implementation levels, there was a decrease
in the average number of new claims filed (1.07 to .36), defense costs ($41,950
to $20,623), settlement costs ($19,480 to $14,228), and total liability costs
($61,430 to $34,851) under collaborative communication resolution program, all
measured per 1000 hospital admissions.
No medical error occurred in 65% of adverse events. One
percent of adverse events when there was no medical error received compensation.
Moreover, the median time interval to resolve a claim
decreased from 17 months to 8 months, a reduction of 53%.
The LeCraw paper describes the CRP
process in detail:
At an initial meeting patient or family members tell their
story and describe the impact of the event. Family members and/or attorneys are
welcome at all meetings and the involved physician or other healthcare provider
representatives are encouraged to attend. The primary goal of the initial
meeting is to listen and learn about the patient’s questions and concerns. Risk
Management (RM) staff describes the resolution process and answers any
questions about it.
The reported event is then investigated through the
hospital’s usual incident investigation processes. A second meeting takes place
between one week and one month after the first. Again, involved physicians may
be invited to attend the second meeting. RM reviews the discussion from the
first meeting and invites the patient to provide any updates. All
non-privileged information about the incident is disclosed to the patient. An
effort is made to reconcile the patient’s version of events with the one
ascertained through the QI investigation. RM staff answers any remaining
questions and agrees to investigate further any unanswered questions.
A patient who is satisfied with the results of the
investigation may wish to conclude the meeting without making any requests. The
study found that in cases where the patient feels that a medical error took
place, the most common requests are for an apology, explanation of the adverse
outcome, and some change in hospital policy or operations. If the adverse
outcome was the result of medical error, the error is acknowledged, and a
sincere apology is given, along with a commitment to change hospital policies
to prevent or minimize the chances of recurrence. (The hospital is only able to
address those elements involving the hospital, unless the physician agrees to
participate.) If compensation is requested by the patient for an adverse
outcome due to medical error, the patient is asked to give a breakdown of the
amount of compensation requested. RM presents this information to the claims
committee, which determines their value for the injury and an amount to offer as
compensation.
If the investigation determines no medical error occurred,
an explanation is made for the adverse outcome and why the hospital believes
the standard of care was not breached. Any request for compensation is denied.
RM staff continues to answer the patient’s clarifying questions and may offer
to participate in mediation if the patient is not satisfied with the
explanation. There is also the potential for a patient who disagrees to
initiate a formal legal claim.
When a medical error occurred and
compensation is requested, a third meeting is proposed no more than 90 days
following initial contact with the patient. Any changes to hospital policy or
procedures resulting from the incident are explained to the patient/family with
an explanation of how the changes are expected to prevent a recurrence. If the patient
accepts the offer of compensation and/or the hospital’s efforts to change
policy, a settlement document is signed. If the offer is rejected, RM staff may
offer to participate in mediation. If all these efforts are unsuccessful, the patient
may still pursue a formal legal claim.
The results achieved
in this CRP program are very reassuring. Also, since attorneys were involved in
60% of the above events, the success reported should be encouraging to
physicians and hospitals alike. Disclosure and sincere apology go a long way to
mend fences when adverse events occur and it’s becoming increasingly clear that
full “communication-and-resolution programs” are satisfying to hospitals
and patients/families and less costly in the long run.
Some of our prior
columns on Disclosure & Apology:
July 24, 2007 “Serious
Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple
Patients”
June 22, 2010 “Disclosure
and Apology: How to Do It”
September 2010 “Followup
to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI:
Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error
Disclosure by Surgeons”
June 2012 “Oregon
Adverse Event Disclosure Guide”
December 17, 2013 “The
Second Victim”
July 14, 2015 “NPSF’s
RCA2 Guidelines”
June 2016 “Disclosure
and Apology: The CANDOR Toolkit”
August 9, 2016 “More
on the Second Victim”
January 3, 2017 “What’s
Happening to “I’m Sorry”?”
October 2017 “More
Support for Disclosure and Apology”
Other very valuable
resources on disclosure and apology:
- IHI’s “Respectful Management
of Serious Clinical Adverse Events” (Conway
2010)
- The Canadian Disclosure
Guidelines (Canadian
Patient Safety Institute 2008)
- The Harvard Disclosure
Guidelines (Massachusetts
Coalition for the Prevention of Medical Errors 2006)
- The ACPE Toolkit (American College
of Physician Executives)
- Oregon Patient Safety
Commission Oregon
Adverse Event Disclosure Guide.
References:
LeCraw FR, Montanera
D, Jackson JP, et al. Changes in liability claims, costs, and resolution times
following the introduction of a communication-and-resolution program in
Tennessee. Journal of Patient Safety and Risk Management 2018; First Published
February 14, 2018; 23(1): 13-18
http://journals.sagepub.com/doi/full/10.1177/1356262217751808
Print “April
2018 More Support for Communication and Resolution Programs”
Joint Commission
and the Second Victim
The Joint Commission recently published a Quick Safety Issue
on supporting second victims (TJC
2018). Our multiple columns on “the second
victim” (see list at the end of today’s column) discuss the evolution of the
approach to helping second victims. Back in the early 1990’s as we began
dealing with investigations on serious events we recognized that those
healthcare workers involved in serious events, either directly or indirectly,
often had difficulty coping in the aftermath of such events. So we added a
specific item to our Serious
Incident Checklist for paying attention to any second victims.
The Joint Commission document notes that it is estimated
that nearly half of health care providers could experience the impact as a
second victim at least once in their career and that a 2014 survey of 1,755
physicians outside the U.S. found most physicians had been involved in a
serious safety event and most admitted to experiencing second victim effects.
TJC notes most hospitals make the same mistake we made in
the early days of patient safety - we often simply made available to second victims
professional assistance (employee assistance programs or psychological
counselling). Over the years, helping the “second victim” has evolved
considerably and such referral for professional help is not a good first line
strategy and may even be counterproductive. Support from peers is extremely important if such programs are to
be successful.
TJC has the following recommendations:
- Instill a just culture
for learning from system defects and communicating lessons learned.
- Engage all team members
in the debriefing process and sharing of the lessons learned from the
event analysis.
- Provide guidance on how
staff can support each other during an adverse event (i.e., how to offer
immediate peer-to-peer emotional support or buddy programs).
- If the EAP is the sole
source of support for second victims, consider creating supplemental
programs after evaluating the EAP’s structure and performance.
It goes on to describe components your organization should
include if you have, or decide to create, a second victim program:
- A strong patient safety
culture, which is an essential foundation for implementation of a
clinician support program.
- Obtain buy-in from
organization leadership and the board.
- Engage executive
champions.
- Develop an educational
campaign to introduce the second victim concept, reduce stigma and biases,
increase awareness and the utilization of services. Staff should know
exactly what to expect if they are involved in an adverse event and how to
access support.
- Develop policies and
procedures, including guidance for direct first responders.
- Develop the program using
evidence-based guidance and ensure that the program is applied fairly
toward all staff.
- Identify the current
confidentiality protections designed for the support program. (Leaders may
want to seek legal counsel about options for preserving confidentiality
since state laws vary.)
- Create additional tiers
of service for those who do not recover with peer support or who endure
litigation.
- Identify professional
resources for external intervention to ensure that the unique needs of
each clinician are met.
- Survey health care
workers to determine benchmarks of program effectiveness (one resource is
the Medically
Induced Trauma Support Services (MITSS) Toolkit noted below).
Repeat the surveys regularly to track progress.
- Measure utilization of
the program, but keep in mind that low rates of use may reflect program
deficiencies or barriers to access rather than lack of need.
- Measure effectiveness of
the program and services; revise the program, if needed.
Our August 2017
What's New in the Patient Safety World column “ROI
for a Second Victim Program”
focused on Johns
Hopkins’ RISE (Resilience In
Stressful Events) program and showed how the efforts made were likely
very cost effective (Moran
2017). In our August 9, 2016 Patient Safety Tip of the Week “More
on the Second Victim” and several other columns we also highlighted the
work of Susan Scott and colleagues at the University of Missouri and their MITSS (Medically Induced Trauma
Support Services) program.
Second victim programs are essential to any organization
that has a good culture of safety. We hope you’ll go to our previous columns on
such programs to see the details of what is involved in such programs.
Some of our prior
columns on “the second victim”:
- December 17, 2013 “The
Second Victim”
- July 14, 2015 “NPSF’s
RCA2 Guidelines”
- June 2016 “Disclosure
and Apology: The CANDOR Toolkit”
- August 9, 2016 “More
on the Second Victim”
- August 2017 “ROI
for a Second Victim Program”
References:
TJC (The Joint Commission). Quick Safety Issue 39:
Supporting second victims. January 22, 2018
Johns Hopkins’ RISE (Resilience In
Stressful Events) program
https://www.johnshopkinssolutions.com/solution/rise-peer-support-for-caregivers-in-distress/
Moran D, Wu AW, Connors C, et al. Cost-Benefit Analysis of a
Support Program for Nursing Staff. Journal of Patient Safety 2017; Post Author
Corrections: April 27, 2017
MITSS (Medically Induced Trauma Support Services)
http://www.mitsstools.org/index.html
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2018 Joint Commission and the Second Victim”
Anesthesia in
Parkinson’s
We don’t tend to focus on one disease in most of our
columns. But there is one particular disease in which
we see numerous complications in hospitalized patients – Parkinson’s Disease
(PD). That is because patients with Parkinson’s are often on medications that
are relatively unfamiliar to inpatient staff and are often on dosing frequency
regimens that don’t fit well with the routines used in hospitals. In addition,
many medications commonly used during hospitalizations may exacerbate symptoms
of Parkinson’s. And
clinical aspects of Parkinson’s may predispose to many other
adverse events in a hospital, including aspiration, falls, DVT, and other
complications related to immobility. Add to that the autonomic dysfunction seen
is some Parkinson’s patients (and more so in some Parkinson-look-alikes such as
Multiple System Atrophy).
We’ve done several columns, listed below, addressing some of
the problems encountered in Parkinson’s patients when inpatients. But we have
not yet addressed surgery and anesthesia. A new study has looked at
considerations for general anesthesia in Parkinson’s patients (Roberts
2018).
Neurology Advisor (Rodriguez
2018) interviewed on of the authors (SJG Lewis) of that review and he had
several important recommendations. First is to continue the usual drug regimen
until just before the induction of anesthesia. This is especially critical in
patients taking levodopa because of the drug's short half-life. During
procedures requiring extended anesthesia, he notes that levodopa can be
administered by means of a nasogastric tube. Second, Propofol has been reported
to demonstrate dyskinetic effects in individuals with and without movement
disorders, including PD, so clinicians should remain aware of the increased
risk for Propofol-induced dyskinesia in deciding whether use of Propofol is
appropriate or not. Third, PD patients often have sialorrhea caused by impaired
swallowing and this may worsen during anesthesia. Glycopyrrolate by mouth and
ipratropium spray have been shown to be effective in short-term treatment of
sialorrhea.
Several commonly used general anesthetic agents, such as
halothane and isoflurane, may influence dopamine transmission. In addition,
they note that halothane has been reported to increase cardiac sensitivity to
catecholamines and should not be used in patients taking levodopa. Sevoflurane,
enflurane, and isoflurane have been suggested as safer alternatives to
halothane.
They also stress that the timing of medications pre- and
post-surgery, is important and that the PD patient is at risk for
neuropsychiatric problems such as psychosis and confusion. If the patient is not
likely to receive alimentation by mouth for a few days postoperatively,
clinicians will need to think about managing the administration of PD
medications. Careful assessment of the PD patient for delirium and agitation is
needed and there should be a plan across specialties for prevention and
management of delirium and/or hallucinations.
There should also be a clear plan for safe rehabilitation of
the patient.
In our three previous columns on PD inpatients, we’ve
stressed that most hospital staff may be unfamiliar not only with medications
taken by PD patients (some of which may not even be on the hospital formulary)
but also with the unique dosing frequencies needed. The very precise timing of doses is problematic for most hospitals and
hospital units because they are used to their own standardized times for
medication dispensing and administration. And most anti-Parkinsonian
medications are available only in oral form so it is
especially problematic when the patient is NPO or is otherwise unable to
swallow. Some anti-Parkinson’s formulations are also of the extended-release
variety and should not be crushed. Moreover, drugs that worsen extrapyramidal
function are often used in the hospital and these may significantly worsen
Parkinsonian features. Patients with Parkinson’s also seem to get temporary
declines in function when they get a systemic problem, like an infection.
Our June 2015 What's
New in the Patient Safety World column “More
Risks for Parkinson Inpatients” highlighted some recommendations ISMP (ISMP 2015)
made for PD inpatients. Hospitals should expedite medication reconciliation and
avoid delays in obtaining nonformulary drugs. They should build computerized
alerts to avoid disease-medication interactions or drug-drug interactions. Each
PD inpatient should have a unique medication administration schedule and drugs
known to worsen PD should be avoided, and sudden cessation of PD meds should be
avoided. ISMP noted the importance of both patient and focused staff education
and noted neurology consultation is advisable. (We would also note that this is
one circumstance where clinical decision support in the form of disease-drug
interactions may be very useful.)
The advice in today’s column regarding the anesthesia
considerations should be added to the complexities of managing PD inpatients.
We’d strongly advise that your neurology staff lead an interdisciplinary team
and establish protocols and training for dealing with PD patients who need
hospitalization and/or surgery.
Our prior columns on
problems related to Parkinson’s Disease patients as inpatients:
- August 2011 “Problems
Managing Medications in Parkinson’s Disease”
- December 2012 “More
on Hospitalized Parkinson’s Disease Patients”
- June 2015 “More
Risks for Parkinson Inpatients”
References:
Roberts DP, Lewis SJG. Considerations for general anaesthesia in Parkinson's disease. J Clin
Neurosci 2018; 48: 34-41
http://www.jocn-journal.com/article/S0967-5868(17)31191-8/fulltext
Rodriguez T. Anesthesia in Parkinson Disease Requires
Cautious Care. Neurology Advisor 2018; February 09, 2018
ISMP (Institute for Safe Medication Practices). Delayed
administration and contraindicated drugs place hospitalized Parkinson’s disease
patients at risk. ISMP Medication Safety Alert! Acute Care Edition. March 12,
2015
http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=103
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2018 Anesthesia in Parkinson’s”
Radiologists Get
Fatigued, Too
One of our most
frequent topics has been the impact of fatigue on performance and its
contribution to medical errors. No one is immune to the detrimental effect of
fatigue on performance and it’s no different for radiologists. A recent study (Hanna 2018)
used a tool for measuring fatigue and advance eye tracking technology to assess
the performance of radiologists (both attendings and residents). The goal was
to determine the effect of overnight shifts on performance.
During each session, radiologists viewed 20 bone radiographs
consisting of normal and abnormal findings. The Swedish Occupational Fatigue
Inventory results demonstrated worsening in all five variables (lack of energy,
physical exertion, physical discomfort, lack of motivation, and sleepiness)
after overnight shifts. Not surprisingly, participants demonstrated worse
diagnostic performance in the fatigued versus not-fatigued state. Viewing time
per case was significantly prolonged when the radiologists were fatigued. Mean total
fixations generated during the search increased by 60% during fatigued sessions.
Mean time to first fixate on bone fractures increased by 34% during fatigued
sessions. Moreover, dwell times associated with true- and false-positive
decisions increased, whereas those with false negatives decreased. Effects of
fatigue were more pronounced in residents.
The authors conclude that further research is needed to
address and reverse the impact of such fatigue-related changes. They speculate
that environmental changes (eg. lighting) and
activity changes (eg. periodic breaks, moving around,
etc.) might help mitigate the adverse effects of fatigue on performance.
Some of our other columns on the role of fatigue in Patient
Safety:
November 9, 2010 “12-Hour
Nursing Shifts and Patient Safety”
April 26, 2011 “Sleeping
Air Traffic Controllers: What About Healthcare?”
February 2011 “Update
on 12-hour Nursing Shifts”
September 2011 “Shiftwork
and Patient Safety
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
January 2012 “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 3, 2012 “Unintended
Consequences of Restricted Housestaff Hours”
June 2012 “June
2012 Surgeon Fatigue”
November 2012 “The
Mid-Day Nap”
November 13, 2012 “The
12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The
12-Hour Nursing Shift: Debate Continues”
October 2014 “Another
Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA
Position Statement on Nurse Fatigue”
August 2015 “Surgical
Resident Duty Reform and Postoperative Outcomes”
September 2015 “Surgery
Previous Night Does Not Impact Attending Surgeon Next Day”
September 6, 2016 “Napping
Debate Rekindled”
April 18, 2017 “Alarm
Response and Nurse Shift Duration”
July 11, 2017 “The
12-Hour Shift Takes More Hits”
Some of our other columns on housestaff
workhour restrictions:
December 2008 “IOM
Report on Resident Work Hours”
February 26, 2008 “Nightmares:
The Hospital at Night”
January 2010 “Joint
Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 2011 “No
Improvement in Patient Safety: Why Not?”
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
January 3, 2012 “Unintended
Consequences of Restricted Housestaff Hours”
June 2012 “Surgeon
Fatigue”
November 2012 “The
Mid-Day Nap”
December 10, 2013 “Better
Handoffs, Better Results”
April 22, 2014 “Impact
of Resident Workhour Restrictions”
January 2015 “More
Data on Effect of Resident Workhour Restrictions”
August 2015 “Surgical
Resident Duty Reform and Postoperative Outcomes”
September 2015 “Surgery
Previous Night Does Not Impact Attending Surgeon Next Day”
March 2016 “Does
the Surgical Resident Hours Study Answer Anything?”
Our previous columns
on the 12-hour nursing shift:
November 9, 2010 “12-Hour
Nursing Shifts and Patient Safety”
February 2011 “Update
on 12-hour Nursing Shifts”
November 13, 2012 “The
12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The
12-Hour Nursing Shift: Debate Continues”
October 2014 “Another
Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA
Position Statement on Nurse Fatigue”
September 29, 2015 “More
on the 12-Hour Nursing Shift”
July 11, 2017 “The
12-Hour Shift Takes More Hits”
References:
Hanna TN,
Zygmont ME, Peterson R, et al. The
Effects of Fatigue From Overnight Shifts on Radiology
Search Patterns and Diagnostic Performance. J Am Coll Rad 2018; Article in
Press January 21, 2018
http://www.jacr.org/article/S1546-1440(17)31661-7/fulltext
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2018 Radiologists Get Fatigued, Too”
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2018 What's New in the Patient Safety World (full column)”
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2018 More Support for Communication and Resolution Programs”
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2018 Joint Commission and the Second Victim”
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2018 Anesthesia in Parkinson’s”
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2018 Radiologists Get Fatigued, Too”
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