PS 105: Responding to Adverse Events

Questions and Answers

What actions should be taken immediately after an adverse event?

Step 1: Care for the patient. Step 2: Communicate with the patient. Step 3: Report to appropriate parties. Step 4: Document in the medical record.

What information should the initial communication include regarding an adverse event?

What happened, how it will affect the patient, a statement of empathy and compassion, and a promise to follow up.

What is the role of a risk manager in the context of delivering difficult information?

A skilled communicator trained in conflict resolution and delivering bad news.

Who should be present during the communication with the patient?

An experienced caregiver familiar with the patient. Signup and view all the answers

What is the purpose of a second clinician being present during the communication?

To help clarify confusing information and to witness what was shared with the patient. Signup and view all the answers

What is the maximum number of people recommended to be in the room during communication about an adverse event?

Two or three. Signup and view all the answers

What are the three guiding points to keep in mind when planning initial communication with a patient?

Keep it simple, express empathy and compassion, and don't place blame. Signup and view all the answers

What should you tell the patient when you are unsure about the details of an error?

Your problem seems to be the result of receiving the wrong dose of medication. Signup and view all the answers

What is the very next action you should take after discovering an adverse event?

Check on the patient and stabilize him. Signup and view all the answers

What should the medical record include regarding the adverse event?

Objective details, patient's condition prior to the event, intervention after the event, notification of physicians, and information shared with the patient. Signup and view all the answers

What are the main reasons for patients and families pursuing lawsuits against caregivers?

All of the above. Signup and view all the answers

What is the proper order of prioritization when an error occurs?

Care for the patient, communicate, report, check medical record. Signup and view all the answers

What is important to do during the initial communication with the patient about an error?

Speak clearly and directly. Signup and view all the answers

What does acknowledgment in an apology include?

The identity of participant(s), appropriate details of the event, and validation that the behavior was unacceptable. Signup and view all the answers

What is required in an explanation part of an apology?

The speaker must accept responsibility and clarify that the patient did not do anything wrong. Signup and view all the answers

What is the purpose of expressing remorse, shame, and humility in an apology?

To show regret for the situation and acknowledge personal limitations. Signup and view all the answers

What does reparation in an apology mean?

Taking steps to make amends for the wrong. Signup and view all the answers

As a parent, how might you feel about a provider diminishing your feelings after a serious medical event?

The provider is minimizing your feelings. Signup and view all the answers

If a provider offers a clear apology incorporating empathy, what might you interpret from that?

The provider is acknowledging their fallibility. Signup and view all the answers

When discussing the event with Mrs.Bernardo, what would be the most appropriate initial comment?

How is your pain? Signup and view all the answers

Why is it important for Janice to apologize to Mrs.Bernardo for the delay in her pain medication?

An apology is needed to maintain provider-patient trust. Signup and view all the answers

Which one of Aaron Lazare's four components of an apology is missing in Janice's apology?

Reparation Signup and view all the answers

When giving an explanation for why an adverse event happened, what is a good idea to do?

Say something like, 'There is just no excuse for what happened.' Signup and view all the answers

Define fundamental attribution error.

Assigning disproportionate blame to individuals involved in an adverse event rather than apportioning responsibility appropriately. Signup and view all the answers

According to Dr. Albert Wu, who are the 'second victims' when an adverse event occurs?

The caregivers involved in the error Signup and view all the answers

What should ideally happen when errors occur?

She should speak calmly with you about what happened. Signup and view all the answers

Why is it important for the organization to offer help and support at this time?

Offering support helps prevent depression or decreased job satisfaction. Signup and view all the answers

Which statement exemplifies a fundamental attribution error?

The HUC almost killed someone yesterday because she doesn't pay enough attention. Signup and view all the answers

Which of the following is a support mechanism that might be available to caregivers after traumatic events?

The Employee Assistance Program Signup and view all the answers

List the seven categories of factors that influence clinical practice and medical error.

Institutional context, organizational and management factors, work environment, team factors, individual staff members, task factors, patient characteristics. Signup and view all the answers

What is root cause analysis (RCA)?

Asking what happened, why it happened, and what can be done to prevent it from happening again. Signup and view all the answers

Define actionable causes.

Causes that are possible to fix. Signup and view all the answers

What is the heart of the RCA process?

Identifying what caused the event. Signup and view all the answers

According to Charles Vincent, what other areas should the team consider in their RCA?

Team factors, institutional context, and organizational factors Signup and view all the answers

Which of the following is an example of a causal statement the team might develop?

The patient was unattended for 30 minutes due to the nurse being busy. Signup and view all the answers

Which intervention is likely to be most effective for improving safety?

Standardizing processes Signup and view all the answers

Study Notes

Immediate Actions After Adverse Events

Prioritize patient care immediately after an adverse event.
Essential steps include communicating with the patient, reporting to relevant parties, and documenting the incident in medical records.

Initial Communication Guidelines

Deliver clear information detailing what occurred and its potential impact on the patient.
Express empathy and maintain ongoing communication, reassuring the patient and family.

Role of Personnel During Communication

Risk managers play a vital role in communicating bad news; they should be paired with a clinician who can address treatment plans.
An experienced caregiver familiar with the patient should be involved in the conversation to provide strong support.

Benefits of Having a Second Clinician

A second clinician can clarify confusing points for the patient and act as a witness to the shared information.

Supportive Presence for the Patient

Involve a case manager or a relative for emotional support and to help the patient retain the conversation’s information, while keeping the group small.

Key Communication Principles

Keep messaging straightforward, express compassion, and avoid assigning blame during initial interactions.

Ideal Patient Responses to Errors

If unsure about specifics, acknowledge the event and express regret without speculation about the cause.
Balance patient care and transparency regarding adverse events.

Prioritization During an Adverse Event

Always address patient care first, followed by communication, reporting, and documentation, ensuring clinical needs are met.

Importance of Open Communication

Transparent communication fosters trust between caregivers and patients and is deemed a fundamental ethical requirement by professional organizations.

Common Barriers to Communication

Caregivers may hesitate to communicate due to fear of disapproval, accountability concerns, and potential legal repercussions.

Components of a Proper Apology

A well-structured apology involves acknowledgment of the mistake, an explanation of the error, expression of remorse, and a commitment to reparation.

Healing Mechanisms Following Medical Errors

Factors like restoration of dignity, assurance of shared values, and entering into dialogue are essential for healing post-adverse events.

Providing Details in the Medical Record

An accurate and impartial account of the unforeseen outcome must include patient condition details, interventions, and communication with involved parties.

Lawsuit Motivations from Patients

Reasons patients might pursue legal action include concerns about care standards, seeking explanations, achieving accountability, and compensating for losses.

Patient Communication After Errors

Initial communication may be emotionally charged; caregivers should not downplay patient experiences or community standards of care.

Necessity of Apologies in Practice

Apologizing is critical for maintaining patient-provider trust, potentially mitigating feelings of guilt and dissatisfaction after an adverse event.

Example of Effective Apology

A complete apology encapsulates recognition of faults, emotional engagement, and clear future corrective measures, enhancing trust and care assurance.### Apology Components
Janice's apology to Mrs. Bernardo lacks reparation, one of Aaron Lazare's four components.
Reparation may include actions like increased check-ups or follow-ups to mend the situation.

Explanation of Adverse Events

The statement "There is just no excuse for what happened" is a dignified response when addressing adverse events.
Explanations should always be factual and clarify that patients are not at fault.

Fundamental Attribution Error

This psychological mistake involves assigning excessive blame to individuals for errors instead of considering organizational factors.

Second Victims Concept

Caregivers involved in adverse events are termed "second victims," highlighting their emotional turmoil and need for institutional support.
These caregivers may experience feelings of guilt, depression, and a decline in job satisfaction post-error.

Supervisory Support

Effective supervision involves calm discussions about the incident and the caregiver's emotional response, rather than punitive measures.

Importance of Organizational Support

Providing support prevents job dissatisfaction and mental health issues for providers involved in errors, regardless of legal obligations.

Identifying Fundamental Attribution Errors

Accusations that place blame solely on individuals, ignoring external factors, exemplify fundamental attribution errors.

Support Mechanisms for Caregivers

The Employee Assistance Program (EAP) offers psychological help and counseling for caregivers after medical errors.

Factors Influencing Clinical Practice and Medical Errors

Seven categories include institutional context, organizational factors, work environment, team dynamics, individual staff, task factors, and patient characteristics.

Root Cause Analysis (RCA)

RCA involves investigating what happened, why, and how to prevent future occurrences, focusing on systemic improvements.

Actionable Causes

Refers to causes that are feasible to address and correct within the organizational framework.

Structure of Causal Statements

Causal statements include the cause ("This happened..."), the effect ("...which led to something else happening..."), and the event ("...which caused this undesirable outcome.").

Team Collaboration in RCA

Diverse perspectives within a team enhance RCA by offering comprehensive insights into errors, despite potential slower processes.

Core Focus of RCA

The essence of RCA is identifying the root causes to facilitate necessary organizational changes.

Additional Factors in RCA

In addition to patient characteristics and work environment, team dynamics and organizational context are essential considerations in RCA, as according to Charles Vincent.

Causal Statements in RCA

Effective causal statements focus on systemic issues rather than placing blame on individuals' actions related to errors.

Effective Interventions for Safety Improvement

Standardizing processes is more effective for enhancing safety than staffing increases, additional training, or warning signs.

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Description

This quiz covers essential actions to take immediately following adverse events in healthcare settings. It highlights communication strategies and documentation procedures critical for patient care. Use these flashcards to reinforce your understanding of responding to such incidents effectively.