1.Presented at the3rd Middle East Patient Safety Conference 17 19 October 2010Presented byKrishnan Sankaranarayanan MBA Senior Officer Patient Safety Department of Performance InnovationTawam Hospital, Al Ain, UAE. Disclosure: The presenter has nothing to disclose, nor has any commercial interest with any of those informations displayed in this presentation.

2. About Tawam Tawam Hospital is a 477-bed tertiary care facilitylocated in Al Ain, Abu Dhabi, and one of the largesthospitals in the United Arab Emirates. In 2006 Tawam Hospital entered a ten year affiliationwith Johns Hopkins Medicine. 3. Subtracting Insult from Injury Statement by: JONATHAN R. COHEN(Assistant Professor, University of Florida) Apologies benefit the victim and the wrongdoer: The Victim feels acknowledged The wrongdoer feels forgivenCohen JR. Advising clients to apologize. Southern California Law Review 1999;72:100969. 4. Ice- Breaker Is there a possibility that the boys death could havebeen due to a medical error? 5. Medical Error- Definition Failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim. (Kohn, et al 2000) Errors can include problems in practice, products, procedures, and systems. 6. Disclosure of medical error-Definition Communication of a health care provider and apatient, family members, or the patients proxy thatacknowledges the occurrence of an error, discusseswhat happened, and describes the link between theerror and outcomes in a manner that is meaningful tothe patient.Fein et al.: Journal of General Internal Medicine, March, 2007: 755-761 Disclosure of medical error is not a singleconversation; rather, it needs to occur over time, in aseries of conversations. Straumanis, 2007 7. Problem Australia: 18,000 annual deaths from Medical errors,1995. U.S: 44- 98,000 Deaths/year (IOM, 1998) United Kingdom: 850,000 incidents/year, 2000. Canada: Adverse events in 7% of Admissions 9-24,000deaths/year. 2004. Middle East: There are lack of statistical evidence inthis region to showcase patient deaths happening dueto medical error. 8. This is what we see? 9. Medical mistakes cases referred - United Arab Emirates: Saturday, June 10 - 2006The UAE Ministry of Health has referred 35 complaints from patients alleging mistakesin their treatment to the Abu Dhabi National Insurance Company, reported Gulf News.The complaints have been reported by patients and investigated over the past sixmonths. The cases have been passed to the insurance company in order to handle anycompensation if it is awarded by the courts 10. What happens after a medical error? 11. Physicians Response For a physician being involved in an error evokesemotions such as shame, humiliation, fear, panic,guilt, anger and self-doubt. (Wu, 1991 & Hilfiker, 1984) Physicians employ several coping mechanisms,including denial and distancing. (Mizrahi, 1984 & Wu, 1993) Causes physicians to feel guarded in their dealingswith patients following an error. (Robin, 1998) 12. Physicians Response The types of suffering are Increased anxiety about the future possibility of errors, Loss of confidence in the work they do, Some face difficulty sleeping, Concern about their reputation as a physician and Reduction in their sense of job satisfaction. Excellent clinicians may leave the profession prematurely when involved in a preventable error.Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. JtComm J Qual Patient Saf 2007;33:46776.Rossheim J. To err is humaneven for medical workers. Healthcare monster. http://healthcare.monster.ca/8099_en-CA_pf.asp (accessed 21Jan 2009). 13. Patients Reactions A common human response to something goingwrong is to ask: What happened? Patients interpret denial, distancing and withdrawal asrejection, and they feel angry and betrayed. This anger and betrayal, coupled with a sense that thephysician is not being honest, that prompts patients tofile claims. (Hickson, 1992, Witman, 1996 & Hingorani 1999) 14. Medical error: the second victim.. The term second victim was initially coined by Wu in hisdescription of the impact of errors on professionals. Thedoctor who makes the mistake needs help too. In the aftermath of a mistake, its important the doctorseek support to deal with the consequences.Albert W Wu associate professorSchool of Hygiene and Public Health and School of Medicine, JohnsHopkins University, Baltimore, MDWu AW (2000). "Medical error: the second victim. The doctor who makes the mistake needs help too". BMJ 320 (7237): 7267. 15. Is disclosure the right thing to do?What professional societies say? American Medical Association has identified itas ethical obligation to disclose. American college of Physicians in its ethicalmanual state that physicians should disclose topatients information about procedural orjudgment errors. American Nurses Association and theAmerican College of Healthcare Executiveshave code of ethics that require professionals torespect human dignity and conduct professionalactivities with honesty. 16. Is disclosure the right thing to do?What professional societies say? Contd. American Society for Healthcare RiskManagement calls for practicing the profession withhonesty and integrity while avoiding unjust harm toothers. National Patient Safety Foundation calls forproviders to disclose medical injury to patients. 17. Disclosure helps in not getting sued.What research says? Full disclosure is found to have a moderating effecton liability and expense payments. Research shows:- (Survey) 24% of patients filed claims because they believed thatthe physicians were not totally honest or covering upimportant information. (Hickson, 1992) 39% of patients would not have filed claims if they hadreceived explanation and an apology. (Vincent 1994) Patients were more likely to sue if they learned of aphysicians error from some other source. (Witman, 1996) 18. Nondisclosure/ Liability Cycle 19. What is the relationship between disclosureand litigation? Failure to disclose leads patients filing claims. Disclosure does not lead to litigation and may in factcurb liability and expense payments. Disclosure helps early and amicable settlement. 20. Significant Barrier A common perception among physicians is that gooddoctors dont make mistakes. Physicians learn to keep mistakes to themselves ratherthan risk the judgment of their peers. The pressure to be perfect is so great that doctorsadmit they would lie to colleagues or patients to coverup a mistake. Out of concern for liability exposure, some doctorshave given up their practices, limited the kinds ofprocedures they perform, or restricted the types ofpatients they seeGreen, M.J., Farber, N.J., and Ubel, P.A. Lying to each other. Archives of Internal Medicine, 2000;160:2317-23.Mizrahi, T. Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Social Science & Medicine,1984;19(2):135-46 21. Significant Barrier- Communication Communication skills are not routinely taught tophysicians or any healthcare provider. In a study 50% of the Physicians said they had neverreceived any formal training on handling medicalmistakes. (Maithel, 1998) In another study physicians agreed disclosure wasrequired, they questioned their ability to do so. (Sweet, 1997 &Gray, 1990) 22. Actions Directed at answering the initial patient worries ofwhat happened?, what is next?, is this fixable? Provider support of the patient must follow quicklyand continue as the process unfolds. Disclosure also restore patients trust in the system. 23. How to Say Im Sorry Detailed account of the situation Acknowledgement of the hurt or damage done Taking responsibility for the situation Recognition of your role in the event Statement of regret Asking for forgiveness A promise that it wont happen again A form of restitution whenever possible 24. Medical Errors and the Full Disclosure/ Early Offer Movement-Doug Wojcieszak Three guiding principles designed to encourage fulldisclosure for medical errors with fair, upfront andearly compensation.1. Compensate quickly and fairly when inappropriate medical care causes injury;2. Defend medically appropriate care vigorously;3. Reduce patient injuries (and therefore claims) by learning from mistakes.Quoted in http://www.sorryworks.net/files/CoalitionPowerpointpresenation.ppt #261,8, Goals of the Coalition 25. Tim McDonald- But Im sorry alone doesnt work. Disclose and apologize doesnt mean the hospitals or doctors say to a patient or family, Something went wrong. Were sorry. Heres a check. Ciao. It means, or should mean, they say something like, You had a bad outcome. We are sorry. We will try to help you while we investigate what happened. If it was our fault, we will take financial and moral responsibility. We will do our best to make sure it never happens again to anyone else.Tim McDonald, a physician and lawyer who is chief safety and risk officer at the University of Illinois health system in Chicago 26. University of Illinois health system in Chicago Patient-family members sit alongside staff on a board charged with overseeing plans to prevent errors Dr. McDonald says that over the past four years, the number of lawsuits against the center is down 40% compared to the period between 1999 and 2004, even though the number of procedures increased 23%Tim McDonald, a physician and lawyer who is chief safety and risk officer at the University of Illinois health system in Chicago 27. Other Examples The University of Michigans program of full disclosure and compensation for medical errors resulted in a decrease in new claims for compensation (including lawsuits), time to claim resolution and lower liability costsA study published Aug. 17 in the Annals of Internal Medicine. 28. Overcoming barriers to error disclosure Culture of blame shift focus to constructive approach- What lessons can we learn?- Are there systems/design issues?- Are there communication issues?- Are there ethical concerns?- How can we improve performance? 29. Overcoming barriers to error disclosure Institution support- Establish disclosure support system Provide disclosure education Ensure disclosure coaching available at all times Provide emotional support (healthcare workers, administration, patients and families) 30. Overcoming barriers to error disclosure Institution support Require medical staff to engage in error disclosure activities Integrate disclosure, patient safety and risk management activities Use performance improvement tools to track and enhance disclosure 31. Overcoming barriers to error disclosure Institution support Provide language interpreter Provide patient-physician liaison Provide system of rewarding error reporting Provide continuing education on error disclosure Provide systems changes to decrease error occurrence 32. Overcoming barriers to error disclosure Role of care providers Participation in disclosure education and skill training Follow guidelines for error reporting Utilize resources for error disclosure Actively lobby for laws Participate in safety and quality improvement activities 33. Overcoming barriers to error disclosure Role of care providers Prepare before meeting with patient and family (RolePlay and practice) Review and know current facts of event Be ready for intense emotion Have legal representation if patient has one Use plain language Do not rush conversation (Never say I know howdifficult it is) - Straumanis, 2007 34. Old proverb till holds good To err is human, to forgive divine - AlexanderPope (1688-1744) Justifying a fault doubles it a French Proverb. 35. How to implement open disclosure Establishing a Culture of Safety Leadership engagement-Achieve buy in from top,bottom & sideways Identify potential champions and possiblestakeholders. Must create an accounting method for remedies. Community involvement and education. Identify and establish Micro system- cultural islocal. Simulation Training- create standardized patients. Celebrating safety- Encourages open reporting. 36. What we have done in Tawam Created the Patient Safety dept Senior Executive Partnership Leadership were trained on Patient Safety Rolled out the Johns Hopkins-Comprehensive Unit-based Safety Program (CUSP). Implemented Patient Safety Net" online incidentreporting system. Instituted the Best Catch Award Created a Patient Safety video (Arabic Version-http://www.youtube.com/watch?v=IkM-V0NIU5U ) 37. References: Courtney J Wusthoff (2001). Medical mistakes anddisclosure: the role of the medical student. JAMA.286:10801081. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ,Levinson W. (2003). Patients and doctors attitudesregarding the disclosure of medical errors. JAMA. 289:10011007. Mazor KM, Simon SR, NGurwitz JH (2004).Communicating with Patients about Medical Errors - AReview of the Literature. Arch Intern Med. 164:16901697. Gert B, Culver CM, Clouser DK (2006) Bioethics: ASystematic Approach. Oxford: Oxford University Press. 38. References: Improving patient safety in hospitals (2002) University of MichiganHealth System Patient Safety Toolkit,http://www.med.umich.edu/patientsafetytoolkit/ accessedSeptember 27, 2009. Perspective on disclosure of unanticipated outcome information(2001). American Society for Healthcare Risk Managemet (AHA)Whitepaper,www.ashrm.org/ashrm/education/development/monographs/Disclosure.2001.pdf accessed September 27, 2009. Gallagher TH, Content of medical error disclosures (2004), VirtualMentor, vol 6 (3), http://virtualmentor.ama-assn.org/2004/03/pfor1-0403.html accessed September 26, 2009. American Medical Association. Code of Medical Ethics of theAmerican Medical Association: current opinions with annotations2006-2007ed. Chicago: AMA, 2006. 39. References: Department of Veterans Affairs (Veterans Health Administration)Disclosure of adverse events to patients: VHA Directive 2008-002.January 18, 2008. American College of Obstetrician Gynecologists Committee OpinionNumber 380, Disclosure and discussion of adverse events (2007),Obstetrics and Gynecology, 2007. Massachusetts Coalition for the Prevention of Medical Errors (2006),When things go wrong: Responding to adverse events A consensusstatement of the Harvard Hospitals, http://www.macoalition.orgaccessed September 26, 2009. Boothman RC, Blackwell AC, Campbell DA, Commiskey E, Anderson S(2009). A better approach to medical malpractice claims? TheUniversity of Michigan experience, J Health & Life Sciences Law, vol2(2), pp. 125-159 40. References: The Joint Commission report. What Did the Doctor Say?: ImprovingHealth Literacy to Protect Patient Safety. (2007). Retrieved Sept. 27,2009, from the Joint CommissionWebsite: http://www.jointcommission.org/nr/rdonlyres/d5248b2e-e7e6-4121-8874-99c7b4888301/0/improving_health_literacy.pdf Gabriel, Barbara A. (Nov. 2007). The Law: Apology Accepted?: Morephysicians are learning to say Im sorry when medical mistakeshappen. Retrieved Sept. 27, 2009, from Physicians PracticeWebsite: http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1084/page/1.htm AMA Code of Medical Ethics: Opinion 8.121 - Ethical Responsibility toStudy and Prevent Error and Harm (Dec. 2003). Retrieved Sept. 27,2009, from the American Medical Association Website:http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion8121.shtml 41. References: Hickson, G. B., Clayton, E. W., Githens, P. B., et al.Factors that prompted families to file medicalmalpractice claims following perinatal injuries. JAMA,1992;267:1359-63. Witman, A. B., Park, D. M., and Hardin, s. B. How dopatients want physicians to handel mistakes? A survey ofinternal medicince patients in an academic setting,Archives of Internal Medicine, 1996;156(22):2565-69. Karaman, S.S., and Hamm, G. Risk management:honesty may be the best policy. Annals of InternalMedicine, 1999:131(12):963-67. Hickson, 1992. 42. References: Vincent, C., Young, M., and Philips, A. Why do people suedoctors? A study of patients and relatives taking legalaction. Lancet, 1994;343:1609-13. Witman, 1996 Stafford v. Shultz, 42 Cal.2d. Kreugar v. St Josephs Hospital, 305 N.W.2d 18. http://www.perfectapology.com/index.html 43. References: Massachusetts Coalition for the Prevention of Medical Errors(2006), When things go wrong: Responding to adverse events Aconsensus statement of the Harvard Hospitals,http://www.macoalition.org accessed September 26, 2009. Perspective on disclosure of unanticipated outcome information(2001). American Society for Healthcare Risk Managemet (AHA)Whitepaper,www.ashrm.org/ashrm/education/development/monographs/Disclosure.2001.pdf accessed September 27, 2009. Improving patient safety in hospitals (2002) University of MichiganHealth System Patient Safety Toolkit,http://www.med.umich.edu/patientsafetytoolkit/ accessedSeptember 27, 2009. Boothman RC, Blackwell AC, Campbell DA, Commiskey E,Anderson S (2009). A better approach to medical malpracticeclaims? The University of Michigan experience, J Health & LifeSciences Law, vol 2(2), pp. 125-159. 44. Apologizing Effectively to Patientsand Families IHI Open School Video 45. RequestOpen disclosure of medical errors is a sensitive topicIt is quite challengingLets make a beginningLets start talking about it 46. Patient Safety Top PriorityCultural change is both evolutionary and revolutionary Thank you