#TPSER9 I reported
yesterday on the distressful case of Stewie, seen to the left, who met his untimely fate when a group of Telluride residents failed to properly execute a team-based procedure. Was this adverse event preventable or not? Poor planning and communication and finger-pointing may have contributed to the failure, but the inexorable law of gravity certainly played a key role.
This afternoon, there was an unexpected interruption, as Stewie's parents broke into the meeting, and the teams were confronted by the angry relatives.
Their comments evoked memories of happier days, when Stewie and his family were closely tied in so many ways. (See below for a picture from the family album.)
But today they demanded answers. "Was Stewie made aware of the risks of this procedure?" "Is there a detailed record of that disclosure?" "Was this the first time the doctors carried out this procedure?" "Is anyone going to be fired?"
The residents responded. They expressed true regret and sympathy, saying also:
It is still too early to understand exactly what happened. As soon, as we know, you will know. We will be totally transparent with you on that point. Yes, he was informed of the risks. It was a fairly new procedure, and I explained that to him. Here are our cards: Please call us at any time, day or night, if you have questions or concerns.
To my readers: How'd they do?
4 comments:
Wow, this is great! Did the residents know this was going to happen? If not, kudos for thinking on their feet.
The only thing I might have done differently is perhaps to be a bit more specific about how you plan to understand what happened. It is critical that they understand there will be a detailed process and procedure for understanding what happened. IMO, anyway.
nonlocal MD
They had no idea is was going to happen. It was a great pedagogical tool, in that we had spent a lot of time yesterday talking, in theory, about how best to interact with families and patients after creating harm.
Here, each team was given five minutes to plan their response to the angry "parents," and one team was chosen to do so in front of the whole class.
They reported afterwards that it was extremely uncomfortable, even though they felt well trained (and even though this was, well, just an egg!) The scenario actually felt very real.
Your suggestion is right on target. I didn't include everything they said, and they did cover the concept you suggest.
I could feel the team's sincerity. I wonder if they could have reached out to them before Stewie family had to come to them in anger? Such bad feelings they will have even if feel a bit better after the facts are figured out. Always better to be proactive if appropriate.
Involve the family in the RCA if possible? And give them a date to get back to them and keep them informed before the date given so they never have to wonder what is going on with the review of care. Then bring them in and have a couple of the team including the physician explain and give them plenty of time. Most families just want to be sure it doesn't happen to others.
My thoughts. Thanks for letting us share in this effort to be better at what we do.
Preventable or not they should have reached out to the family the minute he was injured/died, but their response was appropriate even though late.
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