The Panorama - April 2018

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The Panorama - April 2018

25-Apr-2018

An Update from Regina's Area Chief of Staff, Dr. Juliet Soper

We know from CIHI data that people are harmed while receiving medical care, and that sadly this also occurs in Regina. Our rate of inpatient harm is comparable to the national average. Our goal, however, is to achieve zero harm. Zero harm can only be achieved by recognizing when errors occur, and using these occurrences to drive quality improvement efforts.

With that in mind I want to share with you a recent event I experienced with medical learners. Unfortunately one of my patients suffered harm due to a medication error. A college of medicine learner attended with me when I made the disclosure to the patient and family. We used the incident as a focus for further teaching later that day. I was surprised to hear learners express a dichotomy between teaching received and lived experience; although they are taught to make disclosures they had never observed a senior colleague make a disclosure nor did they believe it actually happened in practice. I therefore feel compelled to highlight the Saskatchewan Health Authority Policy Directive on disclosure of patient safety Incidents (https://sharepoint.ehealthsask.ca/sites/saskhealthauthority/policies/AuthorityPolicies/SHA-02-004.pdf) and share my approach to providing an initial disclosure to a patient and their family.

My approach consists of the following five aspects:

  • Patient care. This involves ensuring the patient is safe, removing exposure to the error, asking about symptoms, examining for signs of associated harm and considering whether further investigations are necessary. Ensure there is appropriate treatment and follow up for any harm that occurred.
  • Disclosure. Make an initial disclosure as soon as reasonably possible. Disclosure involves an explanation of what happened with mention of the error (e.g. medication error) and its impact on the patient (e.g. nausea). An initial disclosure does not indicate the cause or contributing factors as these will not be fully understood until after an analysis of the incident. In situations where patient harm occurred a post-analysis disclosure meeting can be set up with the patient advocate. Remember to document your disclosure encounter.
  • Apology. Apologize to the patient that they have experienced this error and/or harm. It may be worthwhile to acknowledge that the care provided did not meet their expectations, and that their expectations of zero harm are reasonable. An apology does not reflect an admission of guilt.
  • Incident Learning. Ensure incident learning occurs. The nature of this will depend on the location of your practice whether hospital-based or community-based. Every medical error can provide opportunities for system improvement and learning. Within the hospitals of the Regina area the electronic occurrence reports will activate a system learning process through patient safety.
  • Support. Ensure all staff are supported. We all come to work aiming to provide exemplary care to our patients. Every one of us reflects on our role within an incident if a patient has a less than ideal outcome. Know that your colleagues share similar emotions to you in these situations and need the no-blame support of their colleagues. The Saskatchewan Medical Association, Physician Health Program (http://www.sma.sk.ca/programs/44/physician-health-program.html) is available for any physician who needs any level of support. Contact Brenda Senger, Director of Physician Support Programs at (306) 244-2196; 1-800-667-3781 or brenda@sma.sk.ca.

In summary, let's work together to ensure every patient who is exposed to a medical error is safe from further harm, receives a timely disclosure and an apology. Let's also work together to ensure that factors that contributed to the error are recognized and addressed, regardless of whether the incident relates to a medication error, a health care associated infection, a patient accident, or a procedure associated error. Finally let's support each other, particularly when we, or our colleagues, are faced with these difficult situations.

Submitted by: Dr. Juliet Soper, Area Chief of Staff - Regina