Daniel O Connell, PhD

Transcription

1 Daniel O Connell, PhD danoconn@me.com Seattle, WA Disclosing and Resolving Adverse Outcomes And Medical Errors Copyright 2003, Revised 2004, 2006, 2008, 2011 Qualities of an Effective Resolution Ethical Psychologically healing Legal Economical Effective Resolution 1

2 Causes of Unanticipated Outcomes Uncorrected unreasonable expectations Biological variability Low probability risks & side effects Wrong judgments without negligence Individual, team or systems errors and equipment failures Hindsight Bias Universal tendency Seeing events/choices as having been more predictable when looking backwards, after the outcome is known Examples? Which Track? Natural progression of medical condition Inherent risk of investigations or treatments Unanticipated outcome System failure(s) Clinician performance/errors Equipment malfunctions Harm not preventable Harm preventable 2

3 Medical / Systems Error Medical / legal: Act of commission or omission with potential consequences for the patient that would be judged wrong by skilled and knowledgeable peers at the time it occurred. (Wu, 1997) Failure of a planned action to be completed as intended or the use of an incorrect plan to achieve an aim (IOM) Deviation from standard of care An AID to Disclosure A Acknowledge the disappointing event/outcome I Investigate to understand how this happened DDisclose an accurate explanation and pursue resolution Contribution vs. Blame Which feels most fair and answerable by mature professionals? How much do we believe contributed to the adverse outcome? vs. Who is to blame for the adverse outcome? 3

4 When Adverse Event Involves Another Clinician Who should be answering questions about the care provided? The clinician who provided it? A subsequently treating clinician? It sounds like you have concerns about Dr. X s treatment. Since he is in the best position to understand and describe his care, I encourage you to reach out to him with your questions and I will make him aware of your concerns. Approach Shaped by Causation ALEE Anticipate/Adjust Listen Empathize Explain Unanticipated outcome ALEE + Truth, Transparency, and Teamwork Empathy Apology & Accountability Manage until resolved A L E E ANTICIPATE and ADJUST LISTEN for concerns and questions EMPATHIZE and normalize reactions Offer to EXPLAIN what you believe happened 4

5 ALEE: Anticipate and Adjust Anticipate emotions and questions How did this happen? What can be done now? What does it mean for the future? Adjust to meet patient/family needs Begin with an expression of sympathy I was sorry to learn that you had to return to the emergency room. Sympathy or Apology? Express sympathy for their experience I m very sorry you and your family have had to endure so much pain this last week. Apologize for causing harm I m so sorry that our actions have caused you harm. ALEE: Listen Invite their story Please tell me what happened Ask about their Ideas, questions, concerns What are your thoughts about? Feelings How are you feeling at this point? Needs and Motivations How can I be most helpful to you now? 5

6 ALEE: Empathize Being seen Fully present Timely Being heard Summarize to assure understanding Be open to hear their perspective Being understood I understand how it would appear that way. No wonder you are feeling misled. This is very different from what we were all expecting. ALEE: Explain and Answer Questions Ask before explaining Would it be helpful for me to explain? Provide-elicit-provide-elicit to keep conversational and check understanding Avoid inadvertently suggesting liability It sounds like you had a frustrating experience in diagnostic imaging and yet it did not significantly delay our making an accurate diagnosis. : Model for Disclosure Truth and transparency Apology and accountability Empathy for patient and family Manage all aspects O Connell & Reifsteck,

7 T 1 = Truth The conclusion we come to about the most likely causes and contributors to the adverse event or outcome T 2 = Transparency Providing sufficient information for the patient and family to understand what happened and its impact. T 3 = Teamwork Coordinated team to accomplish: Investigation, disclosure discussion, practical assistance and restitution, as appropriate Risk management and liability carriers on board and in agreement 7

8 E= Empathy Demonstrating that we recognize the full impact on the patient and family Medical Psychological Practical Financial A = Apology & Accountability Heartfelt apologies by those who contributed to the harm Accountability to address the causes Some good will come from this M = Manage Until Resolved Exemplary medical care Emotional support for all Patients, families, clinicians Practical assistance Financial compensation? Plan for ongoing follow-up Who, when, what, how 8