Bonnie Haupt, DNP (C), MSN, RN, CNL, CHSE defines disclosure of adverse events and efforts to incorporate best practice components of disclosure into community scenarios 

Case Study

Mr. Sims is a 78 year old white male who presents to the Emergency Room with signs and symptoms of pneumonia. Sims’ wife states he has had increased shortness of breath, a wheezy cough and fever for several days. His vital signs and monitor readings are: oxygen saturation 88-91%; blood pressure 90/50; elevated respiratory rate of 36 and heart rate of 120 sinustach. The team collaborates and believes Mr. Sims is exhibiting signs and symptoms of sepsis requiring transfer to Medical Intensive Care Unit (MICU).

After arrival in the MICU, Sims has continued hypotension (BP 70/40), requiring IV pressors and placement of a triple lumen catheter. The new line is established. While awaiting X-ray placement for confirmation the ER patient experiences increased respiratory rate over 40 and heart rate in the 160s. His wife is expressing concerns to the team that her husband just doesn’t “look right.” Suddenly Sims complains, “I don’t feel right. I can’t catch my breath.” He begins to de-sat quickly and becomes unresponsive. It is identified there are no respirations and no pulse.

The case study reviewed above is a typical simulation scenario that is practiced in many simulation centers across the globe. Yet, how many simulation learning centers are focusing on what happens after the medical crisis? At VA Connecticut Healthcare System we are focusing on creating a collaborative simulation learning experience for Inter-professional and student team members during adverse events. Select simulation scenarios identify relevant practice issues that may constitute disclosure of adverse events and incorporates best practice components of disclosure and communication tips for learners to apply.

Background 

In 1998, The Institute of Medicine (IOM) reported that 98,000 deaths a year were related to medical errors. The IOM findings lead to the final report “Crossing the Quality Chasm” which called for a re-design of America’s healthcare system in 2001 to reduce the number of deaths. Simulation has played an integral role in educating our healthcare teams. According to new research, James (2013) estimates an increase to 210,000 deaths caused by preventable hospital error annually. If factors such as failure to follow guidelines, errors of omission and diagnostic errors are included, the preventable deaths rate jump to 400,000 lives lost annually. How are facilities communicating these unfortunate events to patients and families?

Yale Medical Residents and Interns. Image Credit: Bonnie Haupt.
Yale Medical Residents and Interns. Image Credit: Bonnie Haupt.

Since 2006, the Agency for Healthcare Research and Quality has recommended full disclosure. Other organizations including The Joint Commission, National Patient Safety Foundation and numerous professional ethics councils have voiced clinicians’ legal and ethical obligation to disclose adverse events. The media and families of victims, including actor Dennis Quaid, have brought forth the importance of disclosure.

Key terms requiring understanding by simulation teams incorporating disclosure of adverse events into scenarios include:

  • “Safety” is freedom from accidental injury;
  • “Errors” are planned actions that are not completed as intended; and
  • “Adverse Events” are events that cause patient harm or injury, resulting from a medical interventions, this also includes acts of omission or commission. This implies that something went bad, not necessarily that anyone did anything wrong (IOM, 2012).
Causes of Adverse events result from:
  • Practice related to communication;
  • Mishaps related to equipment malfunction or failure;
  • Procedures related to diagnostic and treatments, this includes failure to make timely diagnosis or institute the appropriate therapeutic interventions. Or, adverse reactions or negative outcomes of treatments; and
  • Systems related to inadequate training (National Center for Ethics in Healthcare, 2003).
Before the IOM report in 1987 VA Lexington Medical Center researched the benefits of full disclosure and found a reduction in financial payments of $15,000 compared to $100,000 nationally (1990-1996). The University of Michigan decreased claim costs from 1995-2007 by $5 million to $1 million (Boothman, Blackwell, Campbell Jr. Commiskey & Anderson, 2009). Several other hospitals have found that full disclosure has dropped malpractice lawsuits by 50% (Lamo, 2011).

Frequently asked questions about disclosure of adverse events have revealed uncertainty among team members. Questions have included:

  • Is there a policy?
  • What events constitute a disclosure?
  • Who is responsible for making the disclosure?
  • When is the appropriate time to address patient and families?
  • What information is communicated and in what manner? andWhat documentation is needed?
This ambiguity has prompted VA Connecticut to incorporate disclosure training into simulation learning experiences.

Methods

Inter-professional and students from diverse backgrounds including medical, nursing, pharmacy, physical/occupational therapy, dietary management, physician’s assistant and respiratory therapy participate in the unique disclosure experiences. Prior to developing the simulation scenario, topics are developed through an analysis of high risk and sentinel events, evidence-based practice issues, policy and procedure skill proficiencies. The goal of each simulation scenario is to improve Veteran safety and outcomes. Code blue-PEA (Pulseless Electrical Activity) /Asystole (TLC insertion), narcotic overdoes with respiratory arrest, blood administration and transfusion reactions, hypoglycemia with a trauma related fall, urinary catheter induced infections, deep vein thrombosis and pulmonary emboli are a few of the scenarios VA Connecticut has developed that include disclosure of adverse events. Following selection of the scenario topic three to five specific objectives are developed. Examples of three PEA objectives might include:

  • Demonstrate effective team communication;
  • Identify common causes of PEA; and
  • Create three (3) situational needs for ethical disclosure in a healthcare setting.
Objectives for disclosure scenarios focus on components of clinical management, team skills and disclosure communication. A treatment outline is developed in a checklist format for participants who are not directly involved to observe and assess participants’ performance. These individuals share what they observed during debriefing. A pre-post quiz designed in  true/false and/or multiple selection formats is given to determine learner knowledge prior to training and post session. During debriefing the team reflects on successes and areas for improvement. All team members have initially focused on the clinical management of the patient.

When team members are asked to address the family member they historically review the code scenario and current treatment plan. Some have commented to the family member, “We saved him.” However, there has been little focus on the adverse event caused by placement of a triple lumen which produced the tension pneumothorax that led to the need for patient saving.

The debriefing discussion shifts to the facility policy, the three specific types of disclosure, the different definitions of use and where to obtain it. The facilitators of the debriefing highlight what warrants a disclosure:

  • Potential to harm or affect patient care;
  • Changes in patients care;
  • Serious future health consequences;
  • Need to provide treatment or procedure without consent and
  • Close call events are advisable.
A disclosure of an adverse event is reviewed with the patient or family member as soon as the practitioner is made aware. Members of the leadership team not limited to Chief of Staff, Nursing Executives, Risk Manager and Inter-professional team members may be included in the family meeting. VA Connecticut has a template in the Computerized Patient Record System and an Online Incident Reporting System where notes are documented.

The major components of disclosure addressed with the teams are to disclose all harmful errors, explain why and how the event happen and explain what process will take place to prevent reoccurrences. A key points and tips brochure on communication highlight items covered in the scenario and completion certificate are provided to the participants.

Tips include:

  • Find a quiet private environment to disclose;
  • Find out what is known and more importantly understood;
  • Speak slowly and in simple terms;
  • Listen;
  • Be empathetic and compassionate;
  • Discuss the investigation;
  • Follow-up and
  • Offer additional support teams.
Evaluation/Findings

A comprehensive evaluation tool was utilized to measure learner’s achievement of each objective. All participants documented that the five main objectives related to Q1 (Question 1). "Recognizes correct medications for use during PEA algorithm." Q2. "Identifies common causes of PEA." Q3. "Demonstrates appropriate ACLS protocol in PEA arrest." Q4."Demonstrates effective team communication during crisis situation." Q5."Identifies ‘3’ situational needs for ethical disclosure in healthcare setting” were met at 100%.

Additional evaluation items were met at greater than 97%. Qualitative data and remarks by the participants included: “Everyone participated as a team during the scenario. I felt important and staff treated us (the students) like we were members of the healthcare team”; “I feel the scenarios will guide me in providing better care to the Veterans”.“I have a clearer understanding of staff roles during crisis situations and disclosure”;

“Very informative, I really liked the interactive scenario and working with many staff who I have never met before, wish to have more” and “It was great to work with the staff during the simulation; this will help me in my clinical interactions with patients and staff. I learned a lot.”

The goal of this initiative is to enhance communication, collaboration and develop a better understanding and respect for inter-professional and student team members’ role in caring for our Nation’s Veterans. Participants have shared their positive feedback of working together on the unique simulation experience.

Conclusion/Implications

The focus on disclosure of information to patients and their families or other indiviudals, continues to be a prominent topic in healthcare. This new innovative idea incorporating use of disclosure into simulation scenarios will close the knowledge gap of ethical health care practices, while continuing to focus on all the key clinical educational components outlined in simulation scenarios. Ethical benefits promote transparency, customer service and trust and may reduce financial claims. The concept promotes positive relationships, improves collaboration, communication and increases understanding of each team member’s role in providing care to our Nation’s Veterans.

About the Author

VA Connecticut Healthcare System

REFERENCES

Agency for Healthcare Research and Quality (AHRQ). (2011). 20 Tips to Prevent Medical Errors. Retrieved from http://www.ahrq.gov/consumer/20tips.htm.

Boothman, R., Blackwell, A., Campbell Jr., D., Commiskey, E., Anderson, S. (2009). A better approach to medical malpractice claims? The university of Michigan experience. Journal of Health & Life Sciences Law. 2,2:125-159.

Brunnquell, D. (2006). What we've learned. Retrieved from http://www.childrensmn.org/web/aboutus/072550.pdf

Gallagher T.,H, Garbutt J.,M, Waterman A.,D, et al. (2006) Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Intern Med.166:1585-1593.

Institute of Medicine. (2003) Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academy Press.

Institute of Medicine. (2001). Shaping the future for health. Crossing the quality chasm: a new health system for the 21st century. Retrieved from Institute of Medicine. (1999). To err is human: Building a safer healthcare system. Washington, DC: National Academy Press.

James, J.,T. (2013). A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety, 9 (3),122–12. doi: 10.1097/PTS.0b013e3182948a69

Joint Commission. (2008). Comprehensive Hospital Accreditation Manual: The Official Handbook. Oakbrook Terrace, IL: Joint Commission Resources.

Kraman, S. S., Hamm, G. (1999). Risk management: Extreme honesty may be the best policy. Annals of Internal Medicine, 131, 12, 963-967.

Lamo, N. (2011). Disclosure of Medical Errors: The Right Thing To Do, But What is the Cost? Retrieved from Senate Committee on Labor, Health, Education and Pensions. Hearing record, June 2006.