Error Reporting and Disclosure.pdf

Orthopedic Technician Module 1.3 Patient Care Skills 10-12 Error Reporting and Disclosure Prepared by Ms. Rawan A. Bukhari BSN, RN Neuro ICU / EMU In KAMC 2024/1445 Objectives: By the end of this lecture, students will be able to understand...

Orthopedic Technician Module 1.3 Patient Care Skills 10-12 Error Reporting and Disclosure Prepared by Ms. Rawan A. Bukhari BSN, RN Neuro ICU / EMU In KAMC 2024/1445 Objectives: By the end of this lecture, students will be able to understand: Ø How to define medical errors and malpractice Ø How often medical errors happen Ø The different types of medical errors Ø How we should disclose and solve medical errors and malpractice Ø The important ethical issues related to medical errors  INTRODUCTION Medical errors ( ME ) is defined as the failure of a planned action to be completed as intended. It is also defined as a preventable adverse medical offense. An ME is also defined as an act or omission that would have been judged wrong by knowledgeable peers at the time it occurred. When an ME occurs, two actions should be considered: reporting it to the health care system (and hence, via this channel, to potential future patients) and disclosing it to the patient involved. Reporting an ME is paramount for quality and safety improvement and the incident should be labeled a “near miss ME”; compared to the reporting of harmful MEs, the reporting of near miss MEs occurs with greater frequency and fewer barriers to data collection. Errors are considered “preventable” and not primarily a result of the disease process. One definition states that an error occurs when there is “failure to complete a planned action as it was intended, or when an incorrect plan is used in an attempt to achieve a given aim”.  COMMON TYPES OF MEDICAL ERRORS ARE AS FOLLOWS: - Surgery-related as in obstetrics and gynecology, general surgery, orthopedic, cardiac and plastic surgery. - Medication-related like mismanagement and possibly incorrect medication, wrong prescription or dosage, and inadequate instructions to patient. - Body-fluid-related error, e.g. blood transfusion administered too quickly, which resulted in congestive heart failure and death. - Diagnostic error, such as misdiagnosis leading to an incorrect choice of therapy. - Failure to order necessary diagnostic test, misinterpretation of test results, and failure to act on abnormal results. - Equipment failure, for instance defibrillators with dead batteries or intravenous pumps whose valves are easily dislodged or bumped which cause increased doses of medication over too short a period. - Others, including medical reports, file errors.  WHY IS THIS SUBJECT IMPORTANT ? - Promote public trust - Prevent further harm to a patient and to other patients - Respect personal autonomy - Support principle of justice - Improve the safety of medical practice -Be able to trust the physicians and the system ETHICAL ISSUES RELATED TO MALPRACTICE Many ethical issues are related to the subject of ME disclosure. According to the principle of justice (fairness) for patients or their families, when harmed, they should be able to seek appropriate restitution. The main ethical issues involved are as follows: 1. Patient autonomy 2. The beneficence of the patient and non-beneficence also 3. Justice: Patients need their rights and right to compensation 4. Truth telling 5. Confidentiality 6. Informed consent 7. The relationship between a physician when he makes a disclosure and the patient, who must be supported, must be transparent ISLAMIC ISSUE RELATED TO MEDICAL ERRORS AND MALPRACTICE There are many issues addressed in Islam that address the subject of the disclosure of medical errors. There is a hadith by the Prophet Muhammad (Peace Be Upon Him) ” ‫) رواه اﺑﻦ ﻣﺎﺟﮫ واﻟﺪارﻗﻄﻨﻲ ( “ ﻻ ﺿﺮر وﻻ ﺿﺮار‬ and its translation is “There should be no harm or return of harm” (Narrated by Ibn- , “ Majah and Al-Daraqotni) which means that we should not harm others (including patients, indeed). There is another hadith by the Prophet Muhammad (Peace Be Upon Him):. ( ‫ وﺻﺤﺤﮫ اﻟﺤﺎﻛﻢ واﻟﺬھﺒﻲ‬، ‫”ﻣﻦ ﺗﻄﺒﺐ وﻟﻢ ﯾﻌﻠﻢ ﻣﻨﮫ طﺐ ﻓﮭﻮ ﺿﺎﻣﻦ " ) رواه أﺑﻮ داوود‬ “Whoever practices medicine when he is not known for that, he is liable.” (Narrated by Abu-Dawood and authenticated by Al-Hakim and Al-Zahaby) ISLAMIC ISSUE RELATED TO MEDICAL ERRORS AND MALPRACTICE Islam should be referred to in order to address patient rights in relation to the three types of medical error. -There is a mistake, error, or negligence -There should be complications -There is a relation between these complications and the mistakes or error  HOW TO IMPROVE OUR PRACTICE BY KNOWING ABOUT MEDICAL NEGLIGENCE We should openly disclose our medical errors because, this will promote public trust as well as justice and will also prevent further harm. Moreover, disclosure respects the patient and his/her autonomy. So, how do we practically disclose medical errors? - Patients want full disclosures of all the errors that result in harm. - And they need to know what has happened and why. - Determine how the problem occurred, any implications, and how to prevent it happening again. One approach to the practical prevention of errors is called the “practical disclosure approach.” Disclosure should take place at the right time, when the patient is medically stable enough to absorb the information, and in the right setting. HOW TO IMPROVE OUR PRACTICE BY KNOWING ABOUT MEDICAL NEGLIGENCE A physician may say, “I’m sorry this has happened.” Patients may appreciate this form of acknowledgement and empathy. This may strengthen, rather than undermine, the physician- patient relationship. The physician himself, or the person who makes the disclosure to the patient (usually the physician), should explain the error in a simple way, immediately, or as soon as possible after he has discussed the problem or error with his senior. He should disclose the error privately, with empathy, and with offers of support. In addition, he should explain what has happened, and if possible state that it will not happen again; he should also support the patient’s right to receive fair compensation. Whatever supports the needs of the patient and his/her family psychologically and physically shall be offered. This practical approach will help to support patients’ rights.  OVR (Occurrence Variance Report ) NAME: ----------------------------------------------------------------------:‫اﻻﺳم‬ MR #: ---------------------------------------------------------- ‫رﻗم اﻟﻣﻠف‬.:‫اﻟطﺑﻲ‬ National ID#: -------------------------------------------.:‫ اﻹﻗﺎﻣﺔ‬/‫رﻗم اﻟﮭوﯾﺔ‬ An occurrence variance 0/‫ﺎﻣ‬,+‫اﳌﺮﻛﺰ اﻟﻄ)* ا‬ SEX: ---------------.:‫ اﻟﺟﻧس‬/ D.O.B: --------------------------- ‫ﺗﺎرﯾﺦ‬ :‫اﻟﻣﯾﻼد‬ report (OVR) or incident report is a NATIONALITY: ------------------------------------------------------.:‫اﻟﺟﻧﺳﯾﺔ‬ Clinic: -----------------.:‫ اﻟﻌﯾﺎدة‬/ Doctor: --------------------------.:‫اﻟطﺑﯾب‬ OCCURRENCE / VARIANCE REPORT principal administrative tool for (‫)ﻻ ﯾﺳﺗﺧدم ھذا اﻟﻧﻣوذج ﻟﻸﻏراض اﻟﺟزاﺋﯾﺔ‬ (Not for Retributive Purposes) Date of Incident: ---------------------------------- Time of Incident: ---------------------- Incident Location: ------------------------------------------- ongoing risk identification as it Date of Report: ------------------------------------ Time of Report: ----------------------- Reporting Area: ---------------------------------------------- Involved Person: □ Patient □ Staff SENTINEL EVENT: □ YES □ NO □ Other: ---------------------------------------------------------------------------- If yes please specify: ------------------------------------------------------------- provides comprehensive facts about □ No Harm Degree OF HARM Communication / Documentation □ Patient Identification Medication --------------------------------------- Clinical Practice / Procedure □ Consent an incident or adverse event. □ Minor Injury □ Severe Injury □ Permanent loss of function or □ Missing files □ Order error □ Documentation □ Medication prescribing error □ Medication dispensing error □ Medication administration error □ Patient Privacy □ Reporting of test result □ Medical notes unavailable disability □ Medical records unavailable □ Medication Storage error □ Policy not available □ Death □ Policy not available □ Refused of cannulation □ Adverse drug reaction □ Confidentiality □ Others □ I.V. not given □ Delay in responding --------------------------------------- □ I.V. infiltration □ Others □ Wrong solution type --------------------------------------- □ Procedure/s not followed □ Others --------------------------- Laboratory Specimen Patient Fall Infection Control □ Improper labeling □ Technical error □ Out of bed □ Off chair □ Needle stick □ Unlabeled specimen container □ Transcription error □ Off scale or equipment □ Sharps injury □ Improper specimen □ Phlebotomy complications □ Found on the floor □ Isolation precaution □ No requisition □ Time delay in processing □ Unknown □ Others compliance □ Incomplete orders □ Result reporting problem □ Used instrument Environmental Safety storage/collection □ Missed specimen □ Infection □ Hazardous material □ Others -------------------------- □ Sample mix-up □ Others □ Security □ Safety □ Fire □ Patient injured (hematoma, etc.) --------------------------------------- □ Medical equipment □ utility □ others ------------ Other Types of Event: ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- Brief description of the incident: ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- Person's current condition: ------------------------------------------------------------------------------------------------------------------------------------ Supervisor Informed? (not required unless immediate action is required) □ Yes □ No Physician informed? □ Yes □ No Immediate Corrective Action: --------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- Reported by: Name: -------------------------------------------------------------------- Clinic/Place: ------------------------------------------------------- Mobile/Ext. no.: ------------------------------------------------------------------------  CASE DISCUSSION Case scenario 1 A 23-year-old medical student was in his last year of medical school. He was asked to perform a procedure he hadn’t done before. His mentor was called away from the operating room about an urgent matter and the young student made a mistake, which led to a complication that caused the woman patient to lose her life.  CASE DISCUSSION Case scenario 1 For this case, which is about Barack, the student who made a mistake: - The senior should not have left the student alone and he should have told him to wait for him to return. - The student should have not have continued by himself; he should have called another senior. - We should educate our students to know their limitations, in both knowledge and skills. - We should disclose any case immediately to the higher authorities for compensation. - The family of a patient should be informed immediately and according to law they should be compensated.  CONCLUSION AND SUMMARY 1. Medical errors or mistakes are not uncommon, and more common in surgical, obstetrics and gynecological, and surgically-related specialties. Drugs also represent an important type of error; others are fluid-related, such as blood transfusions or IV fluids. 2. Patients want a full disclosure of all the errors that result in harm, and they need to know what happened and why, what the implications are, how the problem occurred, and how to prevent it. 3. Disclosure should take place at the right time, when the patient is medically stable enough to absorb the information, and in the right setting. A physician should take the lead in disclosing error(s) to patients and their families. 4. We should disclose our medical error(s) quickly, or as soon as possible, with full disclosure to the patient. We should then offer physical or psychological support, after discussion with our senior colleagues in a calm setting.  REFERENCES 1.Baker GR, Norton PG, Flintcroft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004;170. 2.Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000;320(7237):759-763. 3.Finkelstein D, Wu AW, Holtzman N, et al. When a physician harms a patient by a medical error; ethical, legal, and risk-management considerations. J Clin Ethics 1997;8(4):330-5. 4.Hammami M, Attalah S, Al Qadire M. Which medical error to disclose to patients and by whom? Public preference and perceptions of norm and current practice. BMC Medical Ethics 2010;11(1):17 available from: http://www.biomedcentral.com/1472-6939/11/17. 5.Hobgood C, Weiner B, Tamayo-Sarver JH. Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ? Acad Emerg Med 2006;13:443-51. 6.Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. In: A report of the Committee on Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000. 7.Lansky D. Improving quality through public disclosure of performance information. Health Aff 2002;21(4):52-62. 8.Leape LL. Error in medicine. JAMA 1994;272:1851-7. 9.Levinson W, Roter DL, Mullooly JP, et al. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;277:553-9. 10.Murphy JG, McEvoy MT. Revealing medical errors to your patients. Chest 2008;133:759-63. 11.Singer P, Finnis AM: The Cambridge textbook of bioethics. 1st Edition, 2008.  If you have any question, please contact Ms. Rawan A. Bukhari Email: [email protected] ‫ﺷﻜﺮا ﻟﻜﻢ‬