Errors in community and hospital settings - Part 1 Flashcards
Disclosure Process
● Important to have a disclosure “process” already defined (in advance)
● Process must be flexible to to respond to patient specific scenarios
● “Patient Safety Incident” = “Error”
error sounds negative
near misses generally not told to pt
Stages of the Disclosure Process
● Will typically occur over time (depending on the patient safety incident and
subsequent investigations)
● Initial disclosure (ASAP)
harm results from or a combo of:
- natural progression of med condition
- reconized risj inherent to investigations and tx
- system failure(s)
- provider performance
post-analysis disclosure: leadership/management may lead and providers may still be involved
Saying Sorry
● Part of the apology - viewed as essential by the patient
● Be personal (“I” or “We”)
● Be compassionate
● Express genuine concern
● Starts the process of restoring trust between the healthcare professional (and
or team) and the patient
● Non-verbal communication cues are extremely important
Note: Does saying sorry mean you will be found guilty / liable?
● Alberta Evidence Act - Sec. 26.1(2)(a) - No
Be Honest / Be Tactful
● Respect / Inform / Support
○ Clinically and emotionally
○ “What if this happened to you or a loved one?”
● Avoid assigning blame - state facts known to date
● Use terminology that the patient can understand
○ Active listening and verify understanding
● Consider cultural / language specific needs
● Avoid certain legal words
○ Fault
○ Negligence
○ Not meeting the standard of care
Priority: Help the Patient
If harm occurred, what is being done to minimize further harm to the patient?
● Clinical support measures
○ Outline of the plan
● Emotional support measures
○ Do they need further assistance / support?
● Is a patient representative required?
What Do You Say Next?
● Facts pertaining to the patient safety incident (what is known at the time)
○ Harm to patient (if known)
○ Care to patient (what is known)
○ Events to date (what is known)
● Overview of the next steps in the investigation
○ What
○ When
○ When will the patient expect updates / more information
● Questions from the patient
○ What are they feeling?
○ What is their understanding of the issue?
● Future meeting and contact information (who and how the patient can reach
you)
Recommendations
● In person
● Private setting
● Uninterrupted
● Documentation
● Date / Time / Place / Attendees
● Agreed upon facts / patient’s care plan / Q & A’s / Next steps
● Shared with all attendees
● Typically included in a patient care record
dont wait till end of shift
The Individual
What could happen?
● A review (safety / quality assurance) ○ Root cause analysis => continuous quality improvement ● Discipline (employer based) ● Discipline (regulatory body) ○ Complaint raised by patient ● Criminal lawsuit ● Civil lawsuit
THIS IS REALITY - BUT IS THIS RIGHT?
What is a Safety Culture?
● Just Culture
● Reporting Culture
○ Honestly report ALL Patient Safety Incidents (including near misses)
● Learning Culture
○ Ability to recognize and make changes to existing systems
Just Culture
● Focus shifts away from errors towards systems and behaviours
○ Blame is not focused on the individual
○ BUT - Practitioners held accountable for their choices
● This is NOT a blame free system => it is an accountable system
Example of a Just Culture Approach
read slide 24
A) During the final check stage of the dispensing process, Pharmacist A catches
a prescription that was filled by Pharmacy Assistant 1 with methotrexate
2.5mg tablets instead of metolazone 2.5mg tablets.
B) Pharmacist B was handing out a prescription that was checked by Pharmacy
Technician Alpha. When doing a “show and tell” with the patient and asking
them the Three Prime Questions, based on the patient responses, they
recognized that metolazone 2.5mg tablets was dispensed, but that the patient
did not have high blood pressure.
C) Pharmacist C performed the final check on the prescription that was filled by
Pharmacy Assistant 2 and was subsequently released to T.O. (our scenario).
define impaired judgement malcious action recless action risky action unintentional error
read slide 24
