Jim Conway reports about the release at today's NAHQ* Annual Meeting of a white paper entitled Respectful Management of Serious Clinical Adverse Events. The authors are Jim, Frank Federico, Kevin Stewart, and Mark J. Campbell.
Here's an introductory paragraph:
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; advanced planning for such an event; the balanced prioritization of the needs of the patient, family, staff, and organization; and how actions immediately and over time bring empathy, support, resolution, 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.
Jim offers this comment:
Through the efforts and work of so many, the White Paper is strong. Early response to the content in presentations suggests it can have a significant impact. Ongoing interactions with leaders underscore the need. With its release along with continued learning and improvement, we can achieve a goal we all share in common: In the aftermath of an adverse events, patients, family members, staff and members of the community would say “we were treated with respect and there was learning and improvement."
Lucian Leape provides an early review:
Thank you for this great work. It is evident that it is destined to be THE reference document for organizations everywhere. It is just what is needed. The right balance of theory, explanation, and practical advice. You should be very proud, and we are all very grateful.
Other colleagues have said:
It is extremely well done and is a major resource for the field.
Congratulations to you and your team on this incredible document. Your efforts in pulling this information together should be commended. On behalf of patients, families, health care workers and health care organizations, please keep up your great work and momentum!
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* National Association of Healthcare Quality
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2 comments:
This is very encouraging, in light of a recent article in the Seattle Post Intelligencer (9/27, Nalder). The article reported, “Health care workers, facilities and regulators have been working for years to reduce the astronomical number of medical errors that occur annually.” But “despite their efforts, the country has taken only baby steps toward reducing medical errors that injure and kill hospital patients.” The article continues, “One of the reasons mistakes continue to plague health care is that many facilities are not reporting their mistakes, despite state laws requiring that they do so. Experts say error reporting and analysis leads to improved care over time and ultimately saves lives.” According to a federal study, “underreporting is the norm: the Health and Human Services Inspector General reported that 93 percent of serious adverse events in hospitals went undetected by the hospitals’ own internal reporting systems.”
As with “History”, those who do not disclose and learn from their mistakes are doomed to repeat them.
This comment is very significant. As an inside observer of this progress, I think it is important to distinguish between error and harm. Most serious adverse events reported are too egregious to hide in current environments. But we know that they are the tip of the safety iceberg. 'Errors' are RARELY reported, and few institutions invest in the kind of infrastructure needed to bring them to surface. Electronic records have moved medication error reporting forward, but everyday behavioral and system failures continue to happen without documentation or analysis. Most reporting systems are cumbersome and impractical, and most cultures hierarchical (suppressing reporting and enforcing fears of consequences) and autonomous. We won't make hospitals safer - even with culture change - until we have the tools at hand to know where danger lies and the response at ready to do something about it.
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