Responding to Critical Events: The Human Element Geri Amori, PhD, ARM, DFASHRM, CPHRM VP Academic Affairs Coverys
Disclaimer This presentation is a work product of Coverys Healthcare Provider Education Department. This information is intended to provide general guidelines for risk management. It is not intended and should not be construed as legal or medical advice. COPYRIGHTED
What is your Critical Event Response Plan?
Critical Incident Response Flow Define Categories Trained Incident Command Team Contain Immediate Damage Preserve Evidence Action Plan to Prevent Further Events Determine Causation Investigate Manage Communication Remediation as necessary Continue to Manage Communication
Objectives At the end of this program the participant will be able to: 1. Discuss the human aspects of the critical event investigation process 2. Analyze the barriers to transparent communication with patients and families 3. Describe the Second Victim Phenomenon 4. Discuss Caring for the Professional This means YOU!
Discuss the human aspects of the critical event investigation process OBJECTIVE 1
Critical Event
Post Event Observed Order of Concern Patient Scene Family Causation Staff Potential Litigation You
Primary Concern: Our Patients!
Our Staff
What Happened? How did it Happen? David Coleman: Dreamstime Stock Photos
The War of the Ghost Story
War of the Ghosts Person A: Read the story to yourself Person B: Think of a time when you and another person had a shared event and talked about it years later. It can be a sibling, parent, good friend, spouse or child. Write notes about how what you remembered was different from what they thought was significant about the event or details that you each remember differently.
War of the Ghosts One night two young men from Egulac went down to the river to hunt seals and while they were there it became foggy and calm. Then they heard war-cries, and they thought: Maybe this is a war-party. They escaped to the shore, and hid behind a log. Now canoes came up, and they heard the noise of paddles, and saw one canoe coming up to them. There were five men in the canoe, and they said: What do you think? We wish to take you along. We are going up the river to make war on the people. One of the young men said, I have no arrows. Arrows are in the canoe, they said. I will not go along. I might be killed. My relatives do not know where I have gone. But you, he said, turning to the other, may go with them. So one of the young men went, but the other returned home.
War of the Ghosts, continued And the warriors went on up the river to a town on the other side of Kalama. The people came down to the water and they began to fight, and many were killed. But presently the young man heard one of the warriors say, Quick, let us go home: that Indian has been hit. Now he thought: Oh, they are ghosts. He did not feel sick, but they said he had been shot. So the canoes went back to Egulac and the young man went ashore to his house and made a fire. And he told everybody and said: Behold I accompanied the ghosts, and we went to fight. Many of our fellows were killed, and many of those who attacked us were killed. They said I was hit, and I did not feel sick. He told it all, and then he became quiet. When the sun rose he fell down. Something black came out of his mouth. His face became contorted. The people jumped up and cried. He was dead.
Humans are Witnesses to Events
FBI Retrospective Study 20% overall error rate that led to conviction
Humans Are Unreliable Information Sources
Our Best Intentions Go Awry Ghigomeg Dreamstime.com - Good Intentions Photo
Implications for Patient Safety Interview soon after the event Interview people with differing perspectives (do not be put off by differing stories) Word questions to avoid leading or creating biases Take statements with a grain of salt Look for tell-tale signs of wrestling with truth
Interview Phases Establish purpose and set parameters Establish rapport Questioning Summarization
Wording of Questions: Open-ended first: - What was going on/ What were the conditions at the time of the event that may have contributed to the event happening? (Chaos, multiple conversations, heat, electricity surges, new staff, tired staff, etc.) - What is your memory of the sequence of events? Yes/No second: - Had the monitor been working up until now? - Do you recall anyone turning the volume down? Anything else you think might be useful information?
Interviewer Qualities
Interview Errors Personal biases and jumping to conclusions Taking answers personally Hurrying Making promises you can t keep Placing too much value on minor inconsistencies Under or over-estimating the mental or emotional capacity of interviewees
Mood Barometers Not showing facial expression Blanching (fear) or blushing (embarrassment) Normal eye contact is 30-60% normally Shifting torso to show internal conflict Retreating from threat
Listen Listen.Listen
Analyze the barriers to transparent communication with patients and families OBJECTIVE 2
Successful Disclosure Discussion Hallmarks Respectful Trustworthy Humble Responsible Empathetic Accurate Nondefensive Healing
Successful Disclosure Is Not Manipulative Goal oriented Rushed Blaming Self-flagellating Self-serving Defensive Half-truth
Successful Disclosure Does not necessarily make people happy May result in litigation May result in pay-out
Barriers to Disclosure Iedma, R, Allen, S, Sorensen, R, Gallagher, T. What prevents incident disclosure and what can be done to promote it?. The Joint Commission Journal on Quality and Patient Safety. 2011. 37(9): 409-417
What We ve Learned in 15 Years - from the trenches: It will always be difficult to disclose The patient/family is only ½ the equation Disclosure requires ongoing training & support There will always be difficult surprises Money is a metaphor for power Our personal beliefs about people affects our beliefs about and approach to disclosure The legal and organization systems give mixed messages to both providers and patients/families
Provider Challenges
#1 Recognizing that Disclosure is Appropriate Why do we have to disclose when it s a known complication? No harm, no foul If it can be easily fixed why add to the patient s stress and burden?
#2 Preparing Providers I know how to do this It was all my fault Every complication you ve had to date is because of the small error I made. After all, this is a teaching hospital. I m sorry that Dr. X (the nurse the pharmacy, etc.) did this to you.
#3 Denial That s OK, she was going to die anyway. Disengaged families Provider needing to put positive spin on the outcome
#4 Provider De-brief I felt like they were personally attacking me. I didn t know they would question the decisions I made. I can t believe they want money for such a small mistake. They signed a paper that said these things happen. Why do they think they can sue us? Why did they lie? They said I said I did it. I didn t!
#5 The Assumption that Patients/Families are Happy How come they are not happy that we sat down and talked with them? I can t believe they keep bringing up the same questions. Don t they understand? Why can t they let go?
Surprise Situations in the Meeting Surprise guests at the meeting Patient/Family wanting to record the meeting Demands outside of the scope we can address Cultural issues not previously identified Language challenges Scary threats Media threats Conversation goes directly to money
Retell The War of the Ghost Story
Describe the Second Victim Phenomenon OBJECTIVE 3
Name the first written documentation of the 2 nd Victim Phenomenon
Second Victims Defined Healthcare team members involved in an unanticipated patient event, a medical error and/or a patient related injury and become victimized in the sense that they are traumatized by the event.
Typical Symptoms Gastrointestinal problems Cardiovascular issues Marital difficulties Symptoms of Depression Fatigue Sleep Disturbances Rapid Heart Rate Increased Blood Pressure Rapid Breathing Loss of appetite Frustration Decreased Job Satisfaction Difficulty Concentrating Flashbacks Loss of Confidence Grief / Remorse
Peer Supporters Effective Communicator Integrity Empathy
Challenges to Providing Support Stigma Fear of unknown Ostracization HIPAA Concerns
Retell The War of the Ghost Story
Did You Hear the Same Story 3 Times?
Bartlett on Memory Distortion Assimilation Story becomes consistent with the tellers own cultural experiences Leveling Story becomes shorter with perceived unimportant details omitted Sharpening Order of events changed to make sense in terms of the teller s own cultural norms
War of the Ghosts One night two young men from Egulac went down to the river to hunt seals and while they were there it became foggy and calm. Then they heard war-cries, and they thought: Maybe this is a war-party. They escaped to the shore, and hid behind a log. Now canoes came up, and they heard the noise of paddles, and saw one canoe coming up to them. There were five men in the canoe, and they said: What do you think? We wish to take you along. We are going up the river to make war on the people. One of the young men said, I have no arrows. Arrows are in the canoe, they said. I will not go along. I might be killed. My relatives do not know where I have gone. But you, he said, turning to the other, may go with them. So one of the young men went, but the other returned home.
War of the Ghosts, continued And the warriors went on up the river to a town on the other side of Kalama. The people came down to the water and they began to fight, and many were killed. But presently the young man heard one of the warriors say, Quick, let us go home: that Indian has been hit. Now he thought: Oh, they are ghosts. He did not feel sick, but they said he had been shot. So the canoes went back to Egulac and the young man went ashore to his house and made a fire. And he told everybody and said: Behold I accompanied the ghosts, and we went to fight. Many of our fellows were killed, and many of those who attacked us were killed. They said I was hit, and I did not feel sick. He told it all, and then he became quiet. When the sun rose he fell down. Something black came out of his mouth. His face became contorted. The people jumped up and cried. He was dead.
Discuss Caring for the Professional OBJECTIVE 4
Burnout Kaarsten Dreamstime.com - Burned Out Photo
Ed Isaacs Dreamstime Stock Photos
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