What to do When Things Go Wrong

1. What to do When Things Go Wrong Unit 3 Chapter 8

2. Learning Objective Explore the health care professional’s role in responding to adverse events and the impact this response has on the patient and family.

3. Highlights • Understanding the importance of communication after an adverse event • Identifying the steps which health care professionals would follow after an adverse event • Describing and considering the patient and family perspective after an adverse event including an effective apology

4. Best Practice for Error Disclosure Errors • Individual • System Sentinel Event “an unexpected occurrence or variation involving death or serious physical or psychological injury, or the risk thereof” Galt & Paschal, 2011, p. 123).

5. Near Miss (Close Call) “Is an error that has the potential to do harm but is intercepted before harm actually occurs” (Galt & Paschal, 2011, p. 123).

6. Ethical Frameworks to Consider when Addressing Error Disclosure Ethics is about CHOICE To guide us are: • Ethical theories • Principles • Professional codes of ethics • Ethical-decision-making models • Organizational and institutional guidelines

7. Informing Patients of Errors • Health care professionals have a moral obligation to inform a patient when an error has caused harm • Therapeutic relationship between care provider and patient is built on TRUST • Truthfulness is guided by two commands: ‘Do not lie’ and ‘communicate with those that have a right to know the truth’ • Patients want to know the truth • Benefits of disclosure to an organization are lower liability payments and quality improvement

8. Fear as a Barrier to Error Reporting Galt and Paschal (2011) stated “Blaming and sanctioning create a culture of fear, defensiveness, and often concealment that diminishes both learning and quality improvement” (p. 128). Best practices for reporting errors include: • Deciding WHAT needs to be done immediately • Deciding WHETHER OR NOT to disclose • Deciding WHEN errors should be disclosed • Deciding WHO is the most appropriate person to disclose the error • Deciding to WHOM the disclosure will be communicated • Deciding what COMPONENTS to disclose • Deciding NECESSARY documentation • Offering SUPPORT to the practitioner

9. Legal Aspects of Errors • Galt and Paschal (2011) identified “whenever an error occurs and harm is being done, the patient automatically acquires a legal right to seek compensation for damages.. TORT (p. 138) • Common elements of a tort is: that someone has sustained an injury due to (1) an act or (2) the failure of another to act where the law has imposed a duty • Paying damages is an incentive to prevent future harm The most common tort in health care is ‘negligence’ which has four elements: • A duty owed by one to another • A breach of that duty • Harm or loss • A causal connection between the negligent conduct and the loss or harm suffered

10. Case Study Unit Three Textbook Page 154 Pharmacy Student

11. Professional Negligence Professional negligence is “the failure to exercise the degree of skill and care that is the standard of the professional community” Tort law (medical liability) is the longest standing system used by society for reducing medical error and resulting injury to patients” (Galt & Paschal, 2011, p. 139)

12. Patients want to know when an error has occurred. Most important is an apology. An apology can decrease the chance of legal actions and trust is maintained. Whistle-blowing An error is different than negligence. When health care practitioners observe abusive or negligent care the need to report the practitioner or (whistle blow) is imperative. The purpose is to stop wrongdoing by a person or organization.

13. Whistle-blowing • Whistleblowers place their jobs, reputations, and careers on the line to protect the public. • Not uncommon is retaliation aimed at whistleblowers • If a practitioner knowingly has knowledge of serious misconduct must report the offense or become an accessory to the conduct • Legal rights of whistleblowers: protected under • Criminal Code (2004) (Canada • Public Servants Disclosure Protection Act (2007) (Ontario) • The Public Interest Disclosure (Whistleblower Protection) Act (2013) (Alberta) (Retrieved from http://www.slaw.ca/2013/06/06/the-state-of-whistleblowing-in-canada/)

14. Disclosure of errors is necessary to maintain transparency and trust in health care • A just culture must be created to ensure encouragement and support for promoting safety and being honest with patients is present.

15. Reference Galt, K. A., & Paschal, K. A. (2011). Foundations in patient safety for health professionals. Sudbury, Ma. Jones and Bartlett Publishers.