Abstract
Communication is integral in delivering reliable care in any healthcare setting. Breakdowns in communication often contribute to medical error, while strong communication can frequently prevent medical error. Structured communication during medical care such as a time-out prior to a procedure helps to ensure that all members of the team are ready to proceed. Another way to encourage communication is to support a questioning environment in which members of the team are expected to ask clarifying questions. These strategies can prevent medical error. However, an error may still occur, and organizations must be prepared to respond and disclose to the patient and family. Many professional organizations endorse disclosure as an ethical duty. Hospitals and healthcare systems must support clinicians in disclosing to patients and families. As a part of disclosure, patients and families want to know what happened and how it will be prevented in the future. Through root cause analysis, including interviewing team members, system issues are identified and action plans can be put in place. Following the event and investigation, communicating the details of the event and lessons learned throughout the organization from the frontline to the board is imperative to create a culture of safety, trust, and transparency.
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Chapter Review Questions
Chapter Review Questions
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1.
Effective communication/interview techniques during an event review include:
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A.
Active listening
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B.
Using open-ended questions
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C.
Paraphrasing what was heard
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D.
All of the above
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A.
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Answer: D. Explanation: Verbal communication, from the interviewer to interviewee, should explain the purpose of the investigation, not assign blame and clearly communicate that the interview is being conducted to identify system issues or vulnerabilities [17]. Effective communication techniques of the interviewer include active listening, open questioning, and paraphrasing to verify what was heard.
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2.
Closed-loop communication should be used to:
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A.
Reduce misunderstandings.
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B.
Keep the conversation between two individuals.
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C.
Reduce unnecessary dialogue.
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D.
Convey “you” statements.
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A.
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Answer: A. Explanation: Closed-loop communication is used to clearly communicate information and should explain the purpose of an event, reduce misunderstandings, and can occur in a team setting. It should be non-judgmental as well.
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3.
Full disclosure of an error includes the following except:
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A.
Acknowledgment that an error occurred
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B.
Explanation of the error and harm it caused
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C.
Blaming the person who committed the error
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D.
Treatment plan if harm occurred
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A.
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Answer: C. Explanation: Full disclosure includes an acknowledgment that an error occurred as well as an explanation of the error and connection between the error and harm to the patient and further treatment to mitigate the error. Blaming the individual who committed the error is not productive and not part of the full disclosure process.
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4.
Response to patient harm involves which of the following:
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A.
Establish patient safety.
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B.
Sequester any equipment, devices, or products involved.
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C.
Begin an investigation or review of the event.
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D.
All of the above.
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A.
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Answer: D. Explanation: Response to a patient harm or near miss event should first be to establish patient safety; second to sequester any equipment, devices, or products involved; and to begin an investigation or review of the event. The purpose of an investigation is to gain an understanding of what led to the event’s occurrence and to assist in determining an apparent or root cause(s).
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5.
Significant medical errors leading to harm should be shared with all of the following:
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A.
Patient involved.
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B.
Frontline staff
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C.
Executive leadership
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D.
Board of directors
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E.
Patient safety organization
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F.
All of the above
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A.
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Answer: F. Explanation: Significant medical errors leading to harm should be communicated with all of the above parties to ensure that the patient receives the appropriate treatment in response to the error and to prevent the error from happening again in the institution as well as other institutions.
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Cummins, K., Feley, K.A., Saysana, M., Wagers, B. (2021). Communication with Disclosure and Its Importance in Safety. In: Shah, R.K., Godambe, S.A. (eds) Patient Safety and Quality Improvement in Healthcare. Springer, Cham. https://doi.org/10.1007/978-3-030-55829-1_7
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