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Open Error Communication in a High-Consequence Industry

  • Julianne Morath
  • Mallory Johnson
Chapter

Abstract

In their work as health care professionals, both authors have gained vital experience in error management. They draw our attention to the human tendency to focus only on a single reason when dealing with errors. To mitigate this tendency, they show a two-step alternative process. The first step, a “sequence of events analysis,” is conducted immediately after an accident or near miss. This data capture serves to inform the later, second analysis, called a “focused event analysis.” The focused event analysis is a causal analysis study involving all key stakeholders for the purpose of seeking knowledge about the contributing variables and the steps that can be taken to eliminate system vulnerabilities.

References

  1. Agency for Healthcare Research and Quality. 2016. Hospital survey on patient safety culture. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/index.html
  2. ———. n.d. About the PSO program: A brief history of the program. https://pso.ahrq.gov/about
  3. Ayanian, J.Z. 2003. Is geography destiny? Illuminating the survival advantage of elderly patients in New England after acute myocardial infarction. American Heart Journal 146 (2): 207–209.  https://doi.org/10.1016/s0002-8703(03)00238-2.CrossRefGoogle Scholar
  4. Bari, A., R.A. Khan, and A.W. Rathore. 2016. Medical errors; causes, consequences, emotional response and resulting behavioral change. Pakistan Journal of Medical Sciences 32 (3): 523–528.  https://doi.org/10.12669/pjms.323.9701.CrossRefGoogle Scholar
  5. Bell, S.K., A.A. White, J.C. Yi, J.P. Yi-Frazier, and T.H. Gallagher. 2015. Transparency when things go wrong: Physician attitudes about reporting medical errors to patients, peers, and institutions. Journal of Patient Safety.  https://doi.org/10.1097/pts.0000000000000153.
  6. Bosk, C. 1979. Forgive and remember: Managing medical failure. Chicago: University of Chicago Press.Google Scholar
  7. Chantler, C. 1999. The role and education of doctors in the delivery of health care. Lancet 353 (9159): 1178–1181.  https://doi.org/10.1016/s0140-6736(99)01075-2.CrossRefGoogle Scholar
  8. Dolgin, N.H., B. Movahedi, P.N. Martins, R. Goldberg, K.L. Lapane, F.A. Anderson, and A. Bozorgzadeh. 2016. Decade-long trends in liver transplant waitlist removal due to illness severity: The impact of centers for medicare and medicaid services policy. Journal of the American College of Surgeons 222 (6): 1054–1065.  https://doi.org/10.1016/j.jamcollsurg.2016.03.021.CrossRefGoogle Scholar
  9. Donaldson, L. 2002. An organisation with a memory. Clinical Medicine (London) 2 (5): 452–457.CrossRefGoogle Scholar
  10. Dornfeld, S. 2000. Preventing medical errors. Sint Paul Pioneer Press, July 17, p. 8A.Google Scholar
  11. Editorial Board. 2009. A national survey of medical error reporting laws. Yale Journal of Health Policy, Law, and Ethics 9 (1): 201–286.Google Scholar
  12. Editorial Department. 2000. Children’s hospitals: Worthy effort to improve health care. Star Tribune, p. A12.Google Scholar
  13. Edmondson, A. 2011. Strategies for learning from failure. Harvard Business Review 89 (4): 48–55, 137.Google Scholar
  14. Edmondson, A., M. Roberto, and A. Tucker. 2001. Children’s hospital and clinics. Harvard Business Review. https://doi.org/PRODUCT#: 302050-PDF-ENG
  15. Fabreau, G.E., A.A. Leung, D.A. Southern, M.L. Knudtson, J.M. McWilliams, J.Z. Ayanian, and W.A. Ghali. 2014. Sex, socioeconomic status, access to cardiac catheterization, and outcomes for acute coronary syndromes in the context of universal healthcare coverage. Circulation Cardiovascular Quality and Outcomes 7 (4): 540–549.  https://doi.org/10.1161/circoutcomes.114.001021.CrossRefGoogle Scholar
  16. Fang, J., and M.H. Alderman. 2003. Is geography destiny for patients in New York with myocardial infarction? American Journal of Medicine 115 (6): 448–453.CrossRefGoogle Scholar
  17. Fein, S.P., et al. 2007. The many faces of error disclosure: A common set of elements and a definition. Journal of General Internal Medicine 22 (6): 755–761.  https://doi.org/10.1007/s11606-007-0157-9.CrossRefGoogle Scholar
  18. Gallagher, T.H.S., and W. Levinson. 2007. Disclosing harmful medical errors to patients. New England Journal of Medicine 356 (26): 2713–2719.CrossRefGoogle Scholar
  19. Ghalandarpoorattar, S.M., A. Kaviani, and F. Asghari. 2012. Medical error disclosure: The gap between attitude and practice. Postgrad Medical Journal 88 (1037): 130–133.  https://doi.org/10.1136/postgradmedj-2011-130118.CrossRefGoogle Scholar
  20. Hickson, G.B., E.W. Clayton, P.B. Githens, and F.A. Sloan. 1992. Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA 267 (10): 1359–1363.CrossRefGoogle Scholar
  21. Hingorani, M., T. Wong, and G. Vafidis. 1999. Patients’ and doctors’ attitudes to amount of information given after unintended injury during treatment: Cross sectional, questionnaire survey. BMJ 318 (7184): 640–641.CrossRefGoogle Scholar
  22. Howard Mason, P. 2009. The power of place: Geography, destiny, and globalization’s rough landscape, by Harm de Blij. Anthropology & Medicine 16 (3): 333–336.  https://doi.org/10.1080/13648470903295992.CrossRefGoogle Scholar
  23. Kachalia, A., and D.W. Bates. 2014. Disclosing medical errors: The view from the USA. The Surgeon 12 (2): 64–67.  https://doi.org/10.1016/j.surge.2013.12.002.CrossRefGoogle Scholar
  24. Kohn, L.T., J. Corrigan, and M.S. Donaldson. 2000. To err is human: Building a safer health system. Washington, DC: The National Academies Press.  https://doi.org/10.17226/9728.Google Scholar
  25. Leape, L., et al. 2009. Transforming healthcare: A safety imperative. Quality and Safety in Health Care 18 (6): 424–428.  https://doi.org/10.1136/qshc.2009.036954.CrossRefGoogle Scholar
  26. Lewey, J., and N.K. Choudhry. 2014. The current state of ethnic and racial disparities in cardiovascular care: Lessons from the past and opportunities for the future. Current Cardiology Reports 16 (10): 530.  https://doi.org/10.1007/s11886-014-0530-3.CrossRefGoogle Scholar
  27. Libungan, B. 2015. Acute coronary syndrome and cardiac arrest in the elderly. Doctor of Philosophy (Medicine), University of Gothenburg. Sahlgrenska Academy, Gothenburg, Sweden. https://gupea.ub.gu.se/handle/2077/38347(978–91–628-9294-4)
  28. Lucian Leape Institute. 2015. Shining a light: Safer health care through transparency. A roundtable on transparency. Boston: National Patient Safety Foundation. http://www.npsf.org/?shiningalight
  29. Makary, M.A., and M. Daniel. 2016. Medical error-the third leading cause of death in the US. BMJ 353: i2139.  https://doi.org/10.1136/bmj.i2139.CrossRefGoogle Scholar
  30. Mankiw, N.G. 2007. Principles of microeconomics. 4th ed. Mason: Thomson Higher Education.Google Scholar
  31. Manser, T., and S. Staender. 2005. Aftermath of an adverse event: Supporting health care professionals to meet patient expectations through open disclosure. Acta Anaesthesiologica Scandinavica 49 (6): 728–734.  https://doi.org/10.1111/j.1399-6576.2005.00746.x.CrossRefGoogle Scholar
  32. Martinez, W., and L.S. Lehmann. 2013. The “hidden curriculum” and residents’ attitudes about medical error disclosure: Comparison of surgical and nonsurgical residents. Journal of the American College of Surgeons 217 (6): 1145–1150.  https://doi.org/10.1016/j.jamcollsurg.2013.07.391.CrossRefGoogle Scholar
  33. Martinez, W., et al. 2014. Role-modeling and medical error disclosure: A national survey of trainees. Academic Medicine 89 (3): 482–489.  https://doi.org/10.1097/acm.0000000000000156.CrossRefGoogle Scholar
  34. Mazor, K.M., et al. 2013. More than words: Patients’ views on apology and disclosure when things go wrong in cancer care. Patient Education and Counseling 90 (3): 341–346.  https://doi.org/10.1016/j.pec.2011.07.010.CrossRefGoogle Scholar
  35. McKinney, M. 2012. For better or worse. Report: Where you live affects the type of healthcare you’re going to get. Modern Healthcare 42 (12): 6–7.Google Scholar
  36. McLennan, S.R., M. Diebold, L.E. Rich, and B.S. Elger. 2016. Nurses’ perspectives regarding the disclosure of errors to patients: A qualitative study. International Journal of Nursing Studies 54: 16–22.  https://doi.org/10.1016/j.ijnurstu.2014.10.001.CrossRefGoogle Scholar
  37. Morath, J.M., and J.E. Turnbull. 2005. To do no harm: Ensuring patient safety in health care organizations. San Francisco: Jossey-Bass.Google Scholar
  38. National Patient Safety Foundation. 2009. The universal patient compact. http://c.ymcdn.com/sites/www.npsf.org/resource/resmgr/PDF/UniversalPatientCompact.pdf
  39. Nunn, A., A. Yolken, B. Cutler, S. Trooskin, P. Wilson, S. Little, and K. Mayer. 2014. Geography should not be destiny: Focusing HIV/AIDS implementation research and programs on microepidemics in US neighborhoods. American Journal of Public Health 104 (5): 775–780.  https://doi.org/10.2105/ajph.2013.301864.CrossRefGoogle Scholar
  40. O’Toole, J., and W. Bennis. 2009. What’s needed next: A culture of candor. Harvard Business Review 87 (6): 54–61.Google Scholar
  41. Office for National Statistics’ Death Certification Advisory Group. 2010. Guidance for doctors completing medical certificates of cause of death in England and Wales. http://www.gro.gov.uk/images/medcert_July_2010.pdf.
  42. Periyakoil, V.S. 2008. Geography decides destiny. Journal of Palliative Medicine 11 (5): 694–695.  https://doi.org/10.1089/jpm.2008.9905.CrossRefGoogle Scholar
  43. Plews-Ogan, M., N. May, J. Owens, M. Ardelt, J. Shapiro, and S.K. Bell. 2016. Wisdom in medicine: What helps physicians after a medical error? Academic Medicine 91 (2): 233–241.  https://doi.org/10.1097/acm.0000000000000886.CrossRefGoogle Scholar
  44. Powell, S.K. 2006. When things go wrong: Responding to adverse events: A consensus statement of the Harvard hospitals. Lippincotts Case Management 11 (4): 193–194.CrossRefGoogle Scholar
  45. Pronovost, P.J., et al. 2006. A web-based tool for the Comprehensive Unit-based Safety Program (CUSP). Joint Commission Journal on Quality and Patient Safety 32 (3): 119–129.CrossRefGoogle Scholar
  46. Prouty, C.D., M.B. Foglia, and T.H. Gallagher. 2013. Patients’ experiences with disclosure of a large-scale adverse event. Journal of Clinical Ethics 24 (4): 353–363.Google Scholar
  47. Rosenthal, J. 2007. Advancing patient safety through state reporting systems. Perspectives on safety. https://psnet.ahrq.gov/perspectives/perspective/43/advancing-patient-safety-through-state-reporting-systems
  48. Schwappach, D.L. 2015. In the aftermath of medical error: Caring for patients, family, and the healthcare workers involved. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 58 (1): 80–86.  https://doi.org/10.1007/s00103-014-2083-4.CrossRefGoogle Scholar
  49. Shapiro, J. 2000. Taking the mistakes out of medicine. US News and World Report 129: 50–54.Google Scholar
  50. Snyder, L. 2012. American college of physicians ethics manual. Sixth edition. Annals of Internal Medicine 156 (1 Pt 2): 73–104.  https://doi.org/10.7326/0003-4819-156-1-201201031-00001.CrossRefGoogle Scholar
  51. Statistics Canada. n.d. Canadian vital statistics, death database and population estimates. http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth36a-eng.htm
  52. Stroud, L., B.M. Wong, E. Hollenberg, and W. Levinson. 2013. Teaching medical error disclosure to physicians-in-training: A scoping review. Academic Medicine 88 (6): 884–892.  https://doi.org/10.1097/ACM.0b013e31828f898f.CrossRefGoogle Scholar
  53. The Joint Commission. 2015. Comprehensive accreditation manual. CAMH for hospitals: The official handbook. http://www.jcrinc.com/2016-comprehensive-accreditation-manual-for-hospitals-camh-/
  54. Timmel, J., P.S. Kent, C.G. Holzmueller, L. Paine, R.D. Schulick, and P.J. Pronovost. 2010. Impact of the comprehensive unit-based safety program (CUSP) on safety culture in a surgical inpatient unit. Joint Commission Journal on Quality and Patient Safety 36 (6): 252–260.CrossRefGoogle Scholar
  55. Tsao, K., and M. Browne. 2015. Culture of safety: A foundation for patient care. Seminars in Pediatric Surgery 24 (6): 283–287.  https://doi.org/10.1053/j.sempedsurg.2015.08.005.CrossRefGoogle Scholar
  56. Ubel, P.A. 2014. Transplantation traffic – Geography as destiny for transplant candidates. New England Journal of Medicine 371 (26): 2450–2452.  https://doi.org/10.1056/NEJMp1407639.CrossRefGoogle Scholar
  57. Virginia Mason Institute. 2014. Terrible tragedy – And powerful legacy – of preventable death. https://www.virginiamasoninstitute.org/2014/03/terrible-tragedy-and-powerful-legacy-of-preventable-death/
  58. Wahid, N.N., S.H. Moppett, and I.K. Moppett. 2016. Quality of quality accounts: Transparency of public reporting of never events in England. A semi-quantitative and qualitative review. Journal of the Royal Society of Medicine 109 (5): 190–199.  https://doi.org/10.1177/0141076816636367.CrossRefGoogle Scholar
  59. White, A.A., and T.H. Gallagher. 2013. Medical error and disclosure. Handbook of Clinical Neurology 118: 107–117.  https://doi.org/10.1016/b978-0-444-53501-6.00008-1.CrossRefGoogle Scholar
  60. Yusuf, S., et al. 2011. Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): A prospective epidemiological survey. Lancet 378 (9798): 1231–1243.  https://doi.org/10.1016/s0140-6736(11)61215-4.CrossRefGoogle Scholar

Copyright information

© The Author(s) 2018

Authors and Affiliations

  • Julianne Morath
    • 1
  • Mallory Johnson
    • 1
  1. 1.SacramentoUSA

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