When an error occurs, which of the following is generally the proper order of prioritization?
(A) Communicate with the patient, report to all appropriate parties, check the medical record, care for the patient.
(B) Report to all appropriate parties, check the medical record, care for the patient, communicate with the patient.
(C) Care for the patient, communicate with the patient, report to all appropriate parties, check the medical record.
(D) Check the medical record, care for the patient, communicate with the patient, report to all appropriate parties.
C
The first priority is to address the current health care needs of the patient. After caring for the patient’s immediate clinical needs, start preparing for the initial communication session with the patient and/or the patient’s representative. Various people, departments, entities, or agencies may need to be notified that there has been an adverse event, so once the immediate patient needs are addressed, you’ll want to make sure the proper parties are informed. The last concern is making sure the medical record contains a complete, accurate record of the clinical information pertaining to the unanticipated adverse outcome.
You’re a new resident (house officer). At 2:00 AM, you receive a phone call about a patient you are covering who has diabetes. The patient has an elevated blood sugar of 375. You order 12 units of NovoLog (rapid-acting) insulin and ask the nurse to check the sugar again in one hour and call you back. One hour later, the sugar is 280, so you order another 10 units. By 4:00 AM, the patient’s sugar is dangerously low at 45. You realize that NovoLog insulin takes two to three hours to reach peak effect. By rechecking the patient’s glucose after only one hour and giving more insulin so quickly, you set the patient up for an episode of hypoglycemia.
Why is it important to communicate with the patient about this event?
(A) Open sharing of this type of information is necessary if patients are to trust their caregivers.
(B) Open communication with the patient will prevent the same event from happening again.
(C) Open sharing of this type of information eliminates the risk of a lawsuit.
(D) A and B
A
The best answer is A. Open communication about all outcomes of care, including adverse events, is essential to establish and maintain patient-provider trust. Preventing the same event from happening again will likely require system-level actions, so it will also be important to communicate what happened to people in the organization who have authority to investigate what happened and take action. Although open communication may decrease the risk of lawsuits, it does not eliminate all risk.
Which of the following is true regarding communication about adverse events with patients?
(A) It is important to have all the facts prior to your initial communication about the adverse event.
(B) In some cases, the care team may decide for medical reasons to defer communication with a patient about an upsetting incident.
(C) Due to its complexity, communication with patients following adverse events is best done by lawyers.
(D) All of the above
B
The best answer is B. In some cases, the care team may decide for medical reasons to defer communication with a patient about an upsetting incident. Otherwise, patients have a right to know what happened in their care, and not having all the facts is not a reason to delay communication; just share what you know. Training in communication is helpful, but communicating after an adverse event is not unduly complex, and it should be done by those directly involved in the incident.
If you are responsible for the initial communication with the patient about the error, which of the following should you be sure to do?
(A) Let the patient and family know who is available to help them.
(B) Disguise any feelings of concern or remorse
(C) Explain the exact cause of the error
(D) All of the above
A
It is important to acknowledge that the event occurred and to make it clear who will be available to help the patient and family. You probably don’t know exactly what caused the error at the time of the initial communication, but that’s OK. Rather than completely disguising your feelings, you should express empathy and compassion.
Your organization has a voluntary reporting system for errors. Which of the following incidents should you report?
(A) You are about to administer the wrong medication, but the patient corrects you and is not harmed.
(B) You administer the wrong medication to the patient, and it causes him to feel drowsiness but no pain.
(C) Both A and B
(D) Neither A nor B
C
The best answer is A and B. When people report errors, whether they have negative consequences or not, organizations can learn from them. It is your job to report the errors you experience, and the organization’s job to decide which ones are the highest priority for action.
Janice is a nurse on the orthopedics unit. This night, she is caring for five patients, as well as a new admission from the emergency department. While juggling patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who is in significant pain from a fractured hip. Janice hastily writes down the morphine order from the resident and is then called away when another patient falls out of bed. An hour later, she realizes, to her dismay, that she has not yet given Mrs. Bernardo her pain medication. When she rushes into the room, the patient is crying and asking, “Why won’t someone help me?” Janice quickly administers the morphine.
When discussing the event a little while later with Mrs. Bernardo, the most appropriate initial comment would be:
(A) “How is your pain?”
(B) “Although it took an hour to get the pain medication, we remain committed to making sure you receive excellent care.”
(C) “I apologize for the delay in your morphine.”
(D) “Pain medication can be very tricky, so we are always careful not to give too much, too quickly. Sometimes that means that it takes a while to get your pain under control.”
A
The first and most important issue when a patient receives less than ideal care is to make sure you stabilize and care for the patient. Only after the patient’s safety and comfort are addressed should you consider an apology.
Janice is a nurse on the orthopedics unit. This night, she is caring for five patients, as well as a new admission from the emergency department. While juggling patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who is in significant pain from a fractured hip. Janice hastily writes down the morphine order from the resident and is then called away when another patient falls out of bed. An hour later, she realizes, to her dismay, that she has not yet given Mrs. Bernardo her pain medication. When she rushes into the room, the patient is crying and asking, “Why won’t someone help me?” Janice quickly administers the morphine.
Why is it important for Janice to apologize to Mrs. Bernardo for the delay in her pain medication?
(A) It is not necessary to apologize in this case.
(B) An apology is needed to maintain provider-patient trust.
(C) All institutions require an apology.
(D) An apology will prevent the patient relations department from becoming involved.
B
Janice should apologize because it will help to maintain trust between the patient and her providers — even if there is no permanent injury in this case, the patient certainly experienced more pain than necessary. Although some institutions do not require an apology, providers might want to engage their institutions to reconsider this policy. Apologies should not necessarily prevent the patient relations department from becoming involved after adverse events.
Janice gives the following apology to Mrs. Bernardo: “Mrs. Bernardo, there was a delay in you receiving your pain medication that should not have happened. I am very sorry that you had unnecessary pain. The doctor gave me the order to give you a dose of morphine. However, I was caring for another patient who had fallen, and I got distracted and did not give you the medication as quickly as I should have. Again, I just want you to know how sorry I am that this happened.”
Which one of Aaron Lazare’s four components of an apology is missing in Janice’s apology?
(A) Acknowledgment
(B) Explanation
(C) Expression of remorse or shame
(D) Reparation
D
Reparation, which may simply be an offer to check up more frequently on the patient overnight, is missing in this case. The apology clearly expresses remorse and acknowledges the event, and it provides an explanation without using it as an excuse.
When giving an explanation for why an adverse event happened, it can sometimes be a good idea to:
(A) Give whatever explanation you have at the time, even if some of the information is speculative.
(B) Explain how the patient could have helped prevent the error.
(C) Say something like, “There is just no excuse for what happened.”
(D) All of the above
C
Sometimes the statement “There is no excuse for what happened,” can be the most honest and dignified explanation at the time of your initial apology. Explanations may mitigate or aggravate the patient’s feelings about an event, but they should be factual. The speaker must make it very clear that the patient did not do anything wrong.
According to researchers, which of the following is a common reason why caregivers choose not to communicate when something bad happens?
(A) They feel the harm is not their fault.
(B) They lack empathy for patients and families.
(C) They fear disapproval.
(D) All of the above
C
In the paper discussed in this lesson, published by Banja and colleagues, there were many reasons why providers found it challenging to communicate with patients and families after adverse events, many of which related to fear — fear of disapproval, fear of job loss, fear of anger from the patient, fear of lawsuits, etc. Providers did not discuss lacking empathy for patients and families or feeling that the harm was not their fault.
According to a survey in The Lancet, when patients and families pursue lawsuits against their providers, which of the following is one of the things they want most?
(A) Publicity
(B) Increased public reporting of errors
(C) Tougher laws
(D) An explanation
D
The study found that plaintiffs gave four reasons for suing: the need for an explanation, concern about standards of care, the quest for compensation, and the desire to hold the health care staff or organization accountable. Communication with patients about adverse events, if done well, can address many of these concerns.
Who of the following people might be appropriate to include in an initial conversation with a patient about a medical error in his or her care?
(A) A risk manager
(B) The patient’s physician
(C) The patient’s family
(D) All of the above
D
The physician who is responsible for the patient’s care is usually the best person to have an initial conversation after an error; however, he or she doesn’t have to be alone. For instance, the physician may want a risk manager to accompany him or her — risk managers are skilled communicators trained in conflict resolution and “delivering bad news.” It may also be helpful to have yet another person in the room, such as a case manager or relative, to provide psychological support to the patient and help the patient process and maintain information.
When an adverse event befalls a patient, who are the “second victims” according to Dr. Albert Wu?
(A) The patient’s family
(B) The caregivers involved in the error
(C) The risk managers who become involved in the error
(D) Other patients who might experience the same error in the future
B
The term “second victim,” coined by Dr. Albert Wu, highlights the devastation that caregivers can suffer when they are involved in a medical error, as well as their need for support from colleagues and their institution. After an adverse event, the caregivers involved may feel upset, guilty, self-critical, depressed, and scared. In addition, their job satisfaction, ability to sleep, relationships with colleagues, and self-worth can be negatively affected.
Use the following scenario to answer questions 14-16.
As the Health Unit Coordinator (HUC), it is your job to enter orders from providers into the computer system. You check charts every couple of hours for new orders, unless the providers “flag” the chart by turning a dial on its side to red — in which case, you check the chart right away. On a particularly busy day, you see a chart tucked in a corner and realize that you have not looked at it in at least six hours. Worse, you check the order dial and see that it’s partly red. On the order sheet are orders for “STAT” pain medications and antibiotics for a new patient. You quickly input the orders, your heart pounding. Three hours later, the patient is transferred to the intensive care unit with worsening sepsis (infection).
When your supervisor informs you about what happened, you go numb thinking about those six hours and the cost to the patient. What should ideally happen?
(A) She should speak calmly with you about what happened and how you’re feeling about it.
(B) She should remind you that these errors happen to everyone and they’re no big deal.
(C) She should encourage you to stay busy at work, to help you move past the incident.
(D) She should suspend you immediately, so that you have a couple of weeks to process what happened and learn from your mistake.
A
Ideally, supervisors are trained to spot issues when they arise and to talk calmly with practitioners about what happened. Depending on the circumstances, the caregiver may need to take a break, go home, or take some time off — but there is no reason in this case to think you should be involuntarily suspended.
Why is it important for the organization to offer you help and support at this time?
(A) The organization is legally obligated to do so.
(B) Offering support helps prevent depression or decreased job satisfaction.
(C) Offering support decreases the institution’s legal risk following the error.
(D) Offering support decreases the risk of future errors.
B
There is evidence that the providers involved even in minor errors and near misses can suffer from feelings of shame, depression, and guilt. Sometimes they can be unable to continue their work. Even if the organization has no legal obligation to provide help for providers involved in adverse events, doing so may prevent these negative consequences.
Based on what you know about the incident, which of the following statements seems to be a fundamental attribution error?
(A) “Someone almost died because things were so busy yesterday.”
(B) “The HUC almost killed someone yesterday because she doesn’t pay enough attention.”
(C) “The electronic health record can’t come soon enough — the current system almost killed someone yesterday.”
(D) “I can’t believe what an awful situation the HUC ended up in yesterday; someone almost died.”
B
Three of these statements attribute the error to external factors; however, saying “The HUC almost killed someone yesterday because she doesn’t pay enough attention,” assumes the error occurred as a result of your internal makeup (i.e., you don’t pay enough attention), and is likely a fundamental attribution error. According to the theory of fundamental attribution error, our human tendency is to assume, wrongly, that people’s behavior is a reflection of their personal qualities rather than of the situation in which they find themselves.
Which of the following is a support mechanism that might be available to caregivers after traumatic events?
(A) Care coordination
(B) The Employee Assistance Program
(C) Ombudsmen
(D) The patient relations department
B
A variety of support systems may be available to the caregivers involved in a medical error, including the Employee Assistance Program (EAP), psychological counseling, the local medical society, or organizations such as Medically Induced Trauma Support Services.
Use the following scenario to answer questions 2 and 3:
You’re a new resident (house officer). At 2:00 AM, you receive a phone call about a patient you are covering who has diabetes. The patient has an elevated blood sugar of 375. You order 12 units of NovoLog (rapid-acting) insulin and ask the nurse to check the sugar again in one hour and call you back. One hour later, the sugar is 280, so you order another 10 units. By 4:00 AM, the patient’s sugar is dangerously low at 45. You realize that NovoLog insulin takes two to three hours to reach peak effect. By rechecking the patient’s glucose after only one hour and giving more insulin so quickly, you set the patient up for an episode of hypoglycemia.
Why is it important to communicate with the patient about this event?
(Open sharing of this type of information is necessary if patients are to trust their caregivers.
AND Open communication is essential according to numerous professional codes of conduct)
Use the following scenario to answer questions 2 and 3:
You’re a new resident (house officer). At 2:00 AM, you receive a phone call about a patient you are covering who has diabetes. The patient has an elevated blood sugar of 375. You order 12 units of NovoLog (rapid-acting) insulin and ask the nurse to check the sugar again in one hour and call you back. One hour later, the sugar is 280, so you order another 10 units. By 4:00 AM, the patient’s sugar is dangerously low at 45. You realize that NovoLog insulin takes two to three hours to reach peak effect. By rechecking the patient’s glucose after only one hour and giving more insulin so quickly, you set the patient up for an episode of hypoglycemia.
Which of the following is true regarding communication about adverse events with patients?
Use the following scenario to answer questions 2-3:
Janice is a nurse on the orthopedics unit. This night, she is caring for five patients, as well as a new admission from the emergency department. While juggling patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who is in significant pain from a fractured hip. Janice hastily writes down the morphine order from the resident and is then called away when another patient falls out of bed. An hour later, she realizes, to her dismay, that she has not yet given Mrs. Bernardo her pain medication. When she rushes into the room, the patient is crying and asking, “Why won’t someone help me?” Janice quickly administers the morphine.
When discussing the event with Mrs. Bernardo, the most appropriate initial comment would be:
Use the following scenario to answer questions 2-3:
Janice is a nurse on the orthopedics unit. This night, she is caring for five patients, as well as a new admission from the emergency department. While juggling patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who is in significant pain from a fractured hip. Janice hastily writes down the morphine order from the resident and is then called away when another patient falls out of bed. An hour later, she realizes, to her dismay, that she has not yet given Mrs. Bernardo her pain medication. When she rushes into the room, the patient is crying and asking, “Why won’t someone help me?” Janice quickly administers the morphine.
Why is it important for Janice to apologize to Mrs. Bernardo for the delay in her pain medication?
Janice gives the following apology to Mrs. Bernardo:
“Mrs. Bernardo, there was a delay in you receiving your pain medication that should not have happened. I am very sorry that you had unnecessary pain. The doctor gave me the order to give you a dose of morphine. However, I was caring for another patient who had fallen, and I got distracted and did not give you the medication as quickly as I should have. Again, I just want you to know how sorry I am that this happened.”
Which one of Aaron Lazare’s four components of an apology is missing in Janice’s apology?
Use the following scenario to answer questions 2-4.
As the Health Unit Coordinator (HUC), it is your job to enter orders from providers into the computer system. Direct provider order entry is planned for your hospital next year when the electronic health record is implemented. You check charts every couple of hours for new orders, unless the providers “flag” the chart by turning a dial on its side to red — in which case, you check the chart right away. On a particularly busy day, you see a chart tucked in a corner and realize that you have not looked at it in at least six hours. Worse, you check the order dial and see that it’s partly red. On the order sheet are orders for “STAT” pain medications and antibiotics for a new patient. You quickly input the orders, your heart pounding. Three hours later, the patient is transferred to the intensive care unit with worsening sepsis (infection).
When your supervisor informs you about what happened, you go numb thinking about those six hours and the cost to the patient. What should ideally happen?
Use the following scenario to answer questions 2-4.
As the Health Unit Coordinator (HUC), it is your job to enter orders from providers into the computer system. Direct provider order entry is planned for your hospital next year when the electronic health record is implemented. You check charts every couple of hours for new orders, unless the providers “flag” the chart by turning a dial on its side to red — in which case, you check the chart right away. On a particularly busy day, you see a chart tucked in a corner and realize that you have not looked at it in at least six hours. Worse, you check the order dial and see that it’s partly red. On the order sheet are orders for “STAT” pain medications and antibiotics for a new patient. You quickly input the orders, your heart pounding. Three hours later, the patient is transferred to the intensive care unit with worsening sepsis (infection).
Why is it important for the organization to offer you help and support at this time?
Use the following scenario to answer questions 2-4.
As the Health Unit Coordinator (HUC), it is your job to enter orders from providers into the computer system. Direct provider order entry is planned for your hospital next year when the electronic health record is implemented. You check charts every couple of hours for new orders, unless the providers “flag” the chart by turning a dial on its side to red — in which case, you check the chart right away. On a particularly busy day, you see a chart tucked in a corner and realize that you have not looked at it in at least six hours. Worse, you check the order dial and see that it’s partly red. On the order sheet are orders for “STAT” pain medications and antibiotics for a new patient. You quickly input the orders, your heart pounding. Three hours later, the patient is transferred to the intensive care unit with worsening sepsis (infection).
Based on what you know about the incident, which of the following statements seems to be a fundamental attribution error?
Use the following scenario to answer questions 2-4.
As the Health Unit Coordinator (HUC), it is your job to enter orders from providers into the computer system. Direct provider order entry is planned for your hospital next year when the electronic health record is implemented. You check charts every couple of hours for new orders, unless the providers “flag” the chart by turning a dial on its side to red — in which case, you check the chart right away. On a particularly busy day, you see a chart tucked in a corner and realize that you have not looked at it in at least six hours. Worse, you check the order dial and see that it’s partly red. On the order sheet are orders for “STAT” pain medications and antibiotics for a new patient. You quickly input the orders, your heart pounding. Three hours later, the patient is transferred to the intensive care unit with worsening sepsis (infection).
Which of the following is a support mechanism that might be available to caregivers after traumatic events?
Prathibha, a 29-year-old woman, is recovering from same-day knee surgery. While in the post-anesthesia care unit (PACU), she unexpectedly goes into acute respiratory failure and requires intubation. Because she is a young, healthy woman with no medical problems and this was a very unexpected outcome, the charge nurse convenes a team to conduct a root cause analysis.
As the RCA for this case begins, the team struggles with identification of the root causes of the outcome. They consider the patient’s characteristics as well as the work environment. According to Charles Vincent, what other areas should they consider?
