When the Worst Happens: Responding to Medical Errors
What do you do when a serious mistake occurs that threatens the health of a patient? Studies in human healthcare and a recent veterinary study have shown that our process in responding to medical errors affects the outcome of the patient, the likelihood of legal action by the client, and the long-term resilience of the healthcare team. In addition, the way we respond can also affect the opinion of other veterinarians and the community. The way we deal internally with these issues in coherence with our core values also impacts our team as a whole.
All healthcare team members involved in an error are likely to feel a combination of emotions including fear, guilt, defensiveness and denial. It is important to acknowledge these emotions while responding to an adverse event and finding long term solutions. The following six step process provides a framework for responding to medical errors.
1) The patient should always come first
As soon as a mistake, error, adverse event, potential side effect is noted, care should be taken immediately to minimize ongoing damage, to fix or support body systems, and to get help as needed to improve the chances of a good outcome. In the case of an inadvertent drug delivery or overdose, contacting a poison hotline such as the ASPCA is recommended. In the case of a surgical mistake, consulting with a surgical specialist early should be strongly considered.
2) Notify the client right away
However, the first ethical discussion is which errors should be disclosed? Do you tell clients of every mistake or near miss even if there is no harm? What if the error happened but the patient already had a grave prognosis? What if the error was made by another veterinarian? These are ethical issues we need to discuss as a veterinary community.
In human healthcare, there is strong agreement that any error resulting in serious harm must be disclosed to the patient. In research focus groups, most patients state they want to be informed of ALL mistakes even if no harm resulted.
Clients specifically want explicit acknowledgement that an error occurred. They want to know exactly what the error was and any clinical implications. They want to know WHY the error happened and how recurrences will be prevented. Most importantly, they want a sincere apology and to feel empathy from the team.
Many legal cases occur when people feel that either the medical team is not being honest or because they do not feel that improvement is going to occur. Studies in the human field have shown that disclosure reduces the intent to sue, reduces the size of awards if a case goes to court, and discourages plaintiff attorneys from taking these cases. In 36 states, a statement of apology or sympathy is not admissible in a human malpractice case if it is made quickly after an event.
Ideas to improve disclosure conversations
Initially, describe only what facts you know, not what you assume. Immediately let the client know that their pet’s health is your first concern and that you are caring for them while investigating. Let them know WHEN you will give them more information, WHO will call them, and then STICK to your promise on communication timing. It is important to sincerely express sympathy, support and concern. The phrase to remember is “I’m sorry for what has happened.”
Being mentally prepared for these conversations is important. Many clients will be angry, may yell, and they may request to speak to a different doctor or your supervisor. Discussing scenarios like these ahead of time and having hospital guidelines in place will help the situation go more smoothly.
A program at the University of Michigan was implemented that worked to make sure all harmful errors were disclosed quickly and appropriately and to compensate patients quickly and fairly. Over 5 years, the number of lawsuits dropped by 50%, the time to resolve claims dropped in half, and litigation costs dropped by 2/3. This program is now published as a training module available online here.
3) Support the healthcare workers involved
It is important to deal with the situation at hand without blame. Asking, “Are you OK?” is crucial for healing. Investigation should be centered on forward accountability; how do we learn from the account of what happened to make sure that no one makes this same mistake again in our hospital.
A recent study of 32 shelter veterinarians who had an adverse event occur in spay-neuter surgeries showed that the response of the team to the event was crucial for allowing the veterinarian to process, learn from the event, and to continue to practice. The veterinarians who received support and collegiality, perspective and appraisal, technical learning and emotional learning were more likely to move on and become resilient.
4) Investigate
It is important to understand WHY a mistake or error happened. This is needed to provide a full accounting to the owner and for changing the right things in your hospital. The first glance “why” is usually not the full story. Using the concept of asking why 5 times, will help you look for SYSTEM reasons for mistakes.
5) Circle back to the client
While it is important to talk to the client right away, a fuller discussion should be had after you stabilize the pet, consult experts, and perform an investigation. Clients need closure and a full story so set a time to discuss your findings and your plan after finishing these steps. Set a time not long after the initial event but with enough time to prepare appropriately.
6) Work to fix SYSTEMS internally
The only thing worse than dealing with a medical error is dealing with the same medical error repeatedly. Some initial suggestions for things to mistake proof in your hospital were discussed in this previous blog.
Creating a process to report, track and investigate all medical errors (with and without harm) will allow you to know what mistakes happen and to start the process of continuous improvement. A voluntary system of mistake reporting will only work if errors are viewed as opportunities for learning and system improvement. A reporting system will only work if the staff is involved in brainstorming and implementing changes to help prevent these errors. Programs are most successful when staff are thanked when they report problems and are encouraged to continue being proactive.
Are you interested in learning more about patient safety and quality issues? I will be lecturing on these topics with Gareth Buckley, DVM DACVECC this year at IVECCS, September 2018 in New Orleans.