Saturday, July 5, 2008

Communication Loop Following Adverse Events

Below is a Post I wrote last week but we held off posting it....



All the literature out there tell us that patients and families want several things following bad outcomes and medical errors:

1. They want the truth and in a timely manner.

2. They want either an apology or an acknowledgement.

3. They want to know what the organization is going to do to prevent another occurrence.

4. They want support.

a. emotional support
b. financial support when appropriate

My observation, though, is that many hospitals still struggle with looping back to the patient and family with the information about what happened and how. But, more importantly, they neglect to relay to patients and families the changes to be made moving forward to prevent reoccurrence.


There isn't a mechanism to loop back to staff to give them the same information. I can see why this would be difficult given all the different departments and staff involved. But, I think it just as important that we be transparent with the staff as well. It would also diminish assumptions and rumors among staff.

Does anyone have ideas for how this can be done effectively and routinely?

Does anyone have any suggestions on how we can start doing this better?

...this post seems fitting given the news last week of a Boston Hospital that had done a wrong site surgery. They disclosed to the patient who is recovering at home. But, the President/CEO and the VP of Quality and Safety sent an internal email (click here for full text) letting the staff know about what they described as a horrific incident. I was truly impressed!



Linda Kenney
MITSS

2 comments:

Anonymous said...

Would like to comment on the news today in the Globe about the admission of a local hospital acknowledging the surgical error that occured. I must appaud this hospital in noting in the comments that told this pt about the event once the pt was recovered and alert enough to take it all in. How upsetting for all involved pt, family and staff but how much easier for all involved that from the begining the thought was to allow the pt to become alert enough to take it in and support begun. As we work to encourage disclosure and support I must express to the physicans, staff involved that this step alone will begin to help this pt cope and in the end also help allto move through this process..

Miss Deb said...

The leadership of BIDMC should be congratulated for living out the concept of transparency. Time is a tremendous factor in patient care today. "Fast" and "Efficient" are not necessarily good partners. It also keeps clinicians from thinking about the person who is the patient. Patient makes a person "generic". Maybe one of the new rules for all of us is that we should drop that word and go back to calling people by their proper names. At least then they're more flesh and blood than hospital gown.

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