MSSPNexus Blog

Medical Error: The Second Victim

The doctor (physician assistant, nurse, etc.) who makes the mistake needs help too.

From the British Medical Journal:
http://www.bmj.com/cgi/content/full/320/7237/726

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When I was a house officer another resident failed to identify the electrocardiographic signs of the pericardial tamponade that would rush the patient to the operating room late that night. The news spread rapidly, the case tried repeatedly before an incredulous jury of peers, who returned a summary judgment of incompetence. I was dismayed by the lack of sympathy and wondered secretly if I could have made the same mistake - and, like the hapless resident, become the second victim of the error.

Virtually every practitioner knows the sickening realisation of making a bad mistake.

You feel singled out and exposed - seized by the instinct to see if anyone has noticed. You agonise about what to do, whether to tell anyone, what to say. Later, the event replays itself over and over in your mind. You question your competence but fear being discovered. You know you should confess, but dread the prospect of potential punishment and of the patient's anger. You may become overly attentive to the patient or family, lamenting the failure to do so earlier and, if you haven't told them, wondering if they know.

Sadly, the kind of unconditional sympathy and support that are really needed are rarely forthcoming.

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Can we change this wide-spread healthcare culture and offer support to caregivers involved in mistakes, process failures, and bad outcomes?

To borrow an oft-used phrase from Barack Obama - yes, we can!

One person, one committee, one hospital at a time.

Starting today.

Previous Post: Helping Staff Deal With A Sentinel Event

When Health Care Goes Wrong - Sentinel Events

We all know that mistakes happen in healthcare.  Anyone who has read the Institute of Medicine's To Err is Human Report knows they happen all too often.  Fortunately, most mistakes result in little or no harm to patients.  But what about those events where that is not the case?  The most serious events are referred to as Sentinel, because they signal the need for an immediate investigation and response.

Often, even experienced health care providers are uncertain how to define and respond to sentinel events. Here is a brief overview of both issues, with a focus on the requirements for Joint Commission accredited organizations.

Just what is a Sentinel Event?

Definition:

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

The Improving Organization Performance standard, PI.2.30, requires each accredited organization to define “sentinel event” for its own purposes in establishing mechanisms to identify, report, and manage these events.

Joint Commission Survey Review

In support of its mission to continuously improve the safety and quality of health care provided to the public, the Joint Commission reviews organizations’ activities in response to sentinel events in its accreditation process.

Organization Response:

Accredited organizations are expected to identify and respond appropriately to all sentinel events.

Appropriate response includes conducting a timely (within 45 days of the event, or the organization becoming aware of the event), thorough, and credible root cause analysis and developing an action plan designed to implement improvements to reduce risk. The organization is also expected to monitor the effectiveness of those improvements.

Reporting Sentinel Events to the Joint Commission:

Self-reporting a sentinel event to the Joint Commission is not currently required.  However, whether or not the hospital voluntarily reports the event, the same response, time frames, and review procedures are expected.

Should the Joint Commission become aware of the event, either through survey findings, news reports, a patient complaint, etc., an on-site review generally does not occur unless it appears there is an immediate threat to patient health and safety.

More often, the CEO is contacted and and an assessment of the event is made. Documentation of the root cause analysis and action plan are forwarded to the Joint Commission for review.  After working with the organization, if the JC determines that the documentation and/or response are ineffective, accreditation status can be impacted.

More information regarding Sentinel Event standards from the Joint Commission.   

Job Stress and Healthcare Costs

Feeling stressed at work?  You may end up in the doctor's office.

Health care expenditures are nearly 50% greater for workers who report high levels of stress, according to the Journal of Occupational and Environmental Medicine.

A study published by the National Institute of Occupational Health and Safety reveals that job stress can be defined as the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker. Job stress can lead to poor health and even injury.

The concept of job stress is often confused with challenge, but these concepts are not the same. Challenge energizes us psychologically and physically, and it motivates us to learn new skills and master our jobs. When a challenge is met, we feel relaxed and satisfied. Thus, challenge is an important ingredient for healthy and productive work.

Quintessential Careers reports these common symptoms and early warning signs of job stress and burnout:

• Apathy
• Negativism/cynicism
• Low morale
• Boredom
• Anxiety
• Frustration
• Fatigue
• Depression
• Alienation
• Anger/irritability
• Physical problems (headaches, stomach problems)
• Absenteeism

and offers Ten Tips for dealing with the stress from your job:

1.  Put it in perspective. Jobs are disposable. Your friends, families, and health are not.

10.  Maintain a positive attitude (and avoid those without one). Negativism sucks the energy and motivation out of any situation, so avoid it whenever possible. Instead, develop a positive attitude -- and learn to reward yourself for little accomplishments (even if no one else does).

Read the rest at Managing Job Stress: 10 Strategies for Coping and Thriving at Work from Quintessential Careers.

 

Education Conference in Medical Staff Administration/Credentiailng/Privileging - On the Beach!

I'll be speaking in mid-May at the Alabama & Georgia Association Medical Staff Services combined Spring conference being held in Destin, Florida.

The conference program looks interesting, and Destin beautiful, so if you're looking for education, networking, and CE's in medical staff administration, consider attending. Paul Verardi, an Attorney from Horty Springer speaks on Friday, and I'm certain he'll be a tough act for me to follow on Saturday!

I spoke to this group a couple of years ago, and found them to be both professional and lively, I'm looking forward to being with them again.

Education, friendly folks, and a white sand beach... what could be better?

Hope you can join us in Destin!

Registration Brochure:
http://www.aamss.com/content/2008%20AAMSS%20GAMSS%20Spring%20Conference%20.pdf

Media Coverage of Northern Illinois University Tragedy

His face and name are prominently featured on nearly every news outlet. Statements from his girlfriend indicate that he was not a monster.  Perhaps not, but in the past few days he has certainly become  famous. 

Authorities indicate that becoming famous, even posthumously, is often a major motivating force for mass killers.

Let's take a moment instead, to look at the names of his young victims, and mourn their lost potential.

• Gayle Dubowski, 20
• Catalina Garcia, 20
• Julianna Gehant, 32
• Ryanne Mace, 19
• Daniel Parmenter, 20

Questions (and Answers) of the Week - From Horty Springer

Horty Springer's Question of the Week column has recently featured a couple of interesting scenarios.  Read the questions, decide what you think, and then click on Read the Answer to see whether your thoughts agree with those of the healthcare attorneys at HS:

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Q: An orthopedic surgeon has a standing order on file stating that his physician assistant ("PA") should be called whenever a patient presents to our ED who is in need of a cast or splint. These procedures are within the PA's scope of practice, but we feel really uncomfortable about this situation since the on call physician is not consulted about the specific condition of the patient before the PA is called. We don't think this practice is in compliance with EMTALA. Is it?

Read the Answer

Q: We recently heard through the grapevine that a physician on our staff has been subject to a professional review action at another hospital in town. There have been no problems with his practice here, although he has also never been too busy at our facility. Should we look into what happened at the other hospital?

Read the Answer

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Looking for Dr. Right

Looking for a new doctor? Elizabeth Cohen, author of CNN's Empowered Patient, says it's a lot like looking for a new life partner. She offers tips in Five Ways to Find Dr. Right, including asking your friends to fix you up.

My personal favorite:

3.  Check out the family

Remember, you're not just marrying the doctor. You're marrying the whole family, which for a doctor means the office staff. They're way more important than you might think. When you're feeling desperately ill, you're at their mercy to squeeze you into a packed schedule. "A great doctor who has a grouchy receptionist, rude nurse, careless assistant and obnoxious partner is going to frustrate you," Michael Victoroff says.

The article ends with the thought that like any relationship, don't expect perfection.  I agree, and just like any other important relationship, don't give up at the first sign of trouble; it's worth working at improving respect and communication.  After all, breaking up is hard to do.

Medicare's Budget Woes

Medicare spending makes up 56 percent of the US government's proposed budget. 

Secretary Mike Leavitt warns that the Medicare program, on its current course, is just 11 years from going broke.

Being Number One is a Team Effort

It is an incredibly busy cardiology practice located in the heart of a large hospital complex.  The spacious waiting room was filled nearly to capacity on the day I visited.  I was immediately greeted on arrival by a smiling staff member who dealt efficiently with the computer in front of her.  So far so good.

I sat down in the lobby and observed the comings and goings while I waited.  Some returning patients were greeted warmly by name, and asked how they were feeling. Those with special needs were tended to.  Physicians, nurses and physician assistants breezed back and forth, picking up records and conferring with the front desk staff, complete with a bit of gentle teasing about picking up the pace. 

A family member of a hospitalized patient stopped by to ask for a room number.  Not the appropriate location to make such an inquiry, but the staff member began asking questions to try and locate the patient for the misplaced visitor. 

Street address? 

"I don't know" came the reply.

Date of birth?

"Mom, what's his date of birth?" shouted across the busy waiting room.

After further questioning the staffer apologized that she was unable to locate the individual in the hospital.  The family members milled about, loudly complaining that they'd never seen a hospital that couldn't even find a patient.  Upon calling the patient's cell phone they discovered he'd been discharged.  They left, no thank you to the staff, no apology for taking up their obviously valuable time.

The front-desk staffers remained unruffled through it all.

I was impressed.  I couldn't help but wonder whether these people get the credit they deserve for this particular institution's long-standing selection as a number one heart hospital by US News. 

I hope so.

Grand Rounds 4.21

Grand Rounds 4.21 is up this week at HealthBlawg.  Stop by for a collection of the week's best posts from the medical blogosphere.