When things go wrong in hospitals

My family’s proposed legislation for Kansas requires the disclosure of unanticipated outcomes and medical errors. It also requires hospitals to develop policies for disclosing these unanticipated outcomes and medical errors. Hospital leaders need to realize that tragic events happen in healthcare, and they should have a plan for dealing appropriately with these events.

I learned about a couple resources earlier this week that should help hospitals to develop plans for when things go wrong.

From the IHI: Respectful Management of Serious Clinical Adverse Events

This is a white paper by the Institute for Healthcare Improvement. It is called Respectful Management of Serious Clinical Adverse Events, and can be found on this page. This is a lengthy document (about 50 pages) intended for hospital leaders. It presents an approach to crisis management. The idea behind this approach is that “[o]rganizations and their leaders have a choice: to continue to go into defensive, reactive, survival mode or to go into proactive, learning, developmental mode.”

Here is a quote from the executive summary:

“Every day, clinical adverse events occur within our health care system, causing physical and
psychological harm to one or more patients, their families, staff (including medical staff ), the community, and the organization. In the crisis that often emerges, what differentiates organizations, positively or negatively, is their culture of safety; the role of the board of trustees and executive leadership; advance planning for such an event; the balanced prioritization of the needs of the patient and family, staff, and organization; and how actions immediately and over time address the integrated elements of empathy, disclosure, support (including reimbursement), assessment, resolution (including compensation), learning, and improvement. The risks of not responding to these adverse events in a timely and effective manner are significant, and include loss of trust, absence of healing, no learning and improvement, the sending of mixed messages about what is really important to the organization, increased likelihood of regulatory action or lawsuits, and challenges by the media.”

I read this document last night. It is a very powerful statement of what accountability in a hospital means. If the local hospital that refused to transfer my father to a burn center had followed even a portion of this advice, my family would not be in this infuriating ordeal that has lasted for well over a year.

HealthPact in the state of Washington

HealthPact is a project to “transform communication in healthcare” by a group of researchers and physicians in the the state of Washington. They have developed the Disclosure and Resolution Program that “…gives providers, healthcare institutions and patients the opportunity to collaborate early, communicate effectively and reach resolution expediently following an adverse event.”

Although this is a project underway in only Washington state, I hope that what is learned will inform efforts in other states.


One thought on “When things go wrong in hospitals

  1. Melissa, good day. As an author on the IHI White Paper on Respectful Management of Serious Clinical Adverse Events, I want to thank you for your citation and comments on the paper. The Team has a call today and I was checking in on recent activity on / references to the paper. I was so sorry to hear about your father; my father also died of poor care. Unlike you, we were responded to in a way that we felt was respectful and it was still so hard. Over the years, I have struggled thinking about what families like your family are going through. Congratulations on your careful efforts to get to a different place. To that end, I want to be sure you are aware of all these resources http://www.ihi.org/knowledge/Pages/Tools/LeadershipResponseSentinelEventEffectiveCrisisMgmt.aspx

    Best wishes and thanks for all you are doing. Jim

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