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IN THIS EDITION:
- Registration Information for Sorry Works! Audio Conference
- Indiana Hospital says sorry/offers compensation - applause!
- Making Great Strides with the Insurance Industy
- Question and Answer
- The Pope's "Apology"
- Sorry Works! at Carson City (MI) Hospital
Registration Information for Sorry Works! Audio Conference
The first ever, nation-wide Sorry Works! audio conference will be held on Tuesday, November 14th at 1pm EST - the registration information follows.
To register, contact Melanie Gober at 517-886-8226 (phone), (517) 327-4604 (fax), or e-mail: mgober@rmpsi.com. Live participation on the conference call is $225 per phone line, with a special rate of $150 for educational institutions and MHAIC insureds.
If you can't join us live but want to purchase the audio CD, the cost is $225 ($150 for educational institutions and MHAIC insureds). Finally, we are also offering a live participation/audio CD combo for $275 ($200 for educational institutions and MHAIC insureds).
The conference is a joint project between the Risk Management and Patient Safety Institute (RM&PSI) and The Sorry Works! Coalition.
Dr. Geri Amori, past president of ASHRM, and current RM&PSI senior director will lead and moderate the 90-minute audio conference. The panelists for the audio conference are Dr. Steve Kraman (first physician to implement a hospital-wide disclosure program), Bruce Klores (prominent med-mal plaintiff's attorney), Joe Johnson (med- mal defense attorney for Triad Hospitals), and Doug Wojcieszak (founder/spokesperson, The Sorry Works! Coalition).
The audio conference is a great opportunity for organizations that want to learn more about disclosure, especially hospitals, insurers, and medical organizations that are just beginning the process of evaluating and studying disclosure. The audio conference is also a wonderful teaching tool for professors and instructors working with future healthcare, insurance, and legal professionals.
Be sure to register today. Furthermore, please let your colleagues and friends know about the audio conference...spreading the word about this event is a great and easy way to help Sorry Works! Thanks.
Indiana Hospital says sorry/offers compensation - applause!
Indiana Methodist Hospital (located in Indianapolis) made national and international headlines this week for publicly apologizing to the families of two premature infants killed by a drug overdose (four other infants were given the overdose too, with one infant still in critical condition.)
Hospital leadership has met with the families, apologized, admitted fault, and offered compensation. They have also vowed to fixed their processes so the same error is never repeated.
In short, this is Sorry Works! in action. The four elements of effective apology (remorse, admission of fault, explanation of how the mistake will be prevented in the future, and compensation) are present. Hospital leaders invited Sorry Works! to speak to their leadership last summer (2005), and it appears our message resonated. We applaud the hospital leadership and encourage other hospitals and med-mal insurers to follow their lead.
Below is an article written and published by the Associated Press on the story with quotes from Sorry Works! Please forward to colleagues.
For more information on Sorry Works! speaking engagements and teaching programs, contact 618-559-8168 or e-mail doug@sorryworks.net.
AP Centerpiece: Hospital apology could go a long way
DEANNA MARTIN and JENNY MONTGOMERY
Associated Press
Tue, Sep. 19, 2006
INDIANAPOLIS - Methodist Hospital has changed the way drugs are handled since six premature infants were given overdoses of a blood thinner, causing two girls to die.
Hospital officials also have apologized to the affected families, which advocates say is often one of the most important steps after such medical mistakes are made. Hospital leaders on Tuesday added that they would financially compensate the families for their loss.
Expressions of regret and offers of up-front payments do not always come so quickly after such mistakes, said Doug Wojcieszak, the founder the Sorry Works! Coalition, a group that advocates more openness in reporting medical errors.
Although money might not be what grieving families want now, it could take away some anger later, said Wojcieszak, who said he lost a brother to medical error.
"They've had their hope and their love tied up in their children, and then something like this happens," he said. "Obviously you can never replace a life, but people need healing. They need people to take ownership of those mistakes."
Of the four other infants who were given the overdose, three were in stable condition, while a fourth was in critical and unstable condition, officials said.
Methodist has blamed the overdoses on human and procedural errors. Heparin comes in premeasured vials, which hospital pharmacy technicians place in a computerized drug cabinet.
Early Saturday morning, a technician with more than 25 years experience took the wrong dosage from inventory and stocked it in the drug cabinet in the Newborn Intensive Care Unit, officials. Nurses accustomed to only one dosage of heparin being available administered the wrong amount.
Emmery Miller and D'myia Alexander Nelson, both less than a week old, died.
Methodist was solely responsible for the error, said Sam Odle, president and CEO of Methodist Hospital, which is part of Clarian Health Partners.
"Of course we have offered our apologies and our deepest regrets," Odle said. "Ultimately the blame for our errors falls upon the institution. A weakness in our own system has been exposed and has been corrected."
Medical errors are estimated to kill thousands of people each year - some studies put the number between 44,000 and 98,000. Cases similar to the problem at Methodist have happened before.
In 1990, three premature infants died in Philadelphia after receiving an incorrectly mixed intravenous solution. In 1991, two premature babies died in Dallas after being overdoses of an antibiotic when a hospital technician prepared the wrong mixture.
Jim Conway, a senior fellow at the Institute for Healthcare Improvement said hospitals need to work to find ways to prevent errors.
"Every one of us will make mistakes, and it's the responsibility of health-care organizations to put in place systems that support safe practice," Conway said.
Some hospitals and doctors have resisted in the past admitting mistakes publicly because they fear lawsuits.
But certain reporting systems allow hospitals to report errors without the fear of a lawsuit, said Rick Croteau, with the Joint Commission on Accreditation of Healthcare Organizations.
"We are seeing, in effect, a shift in the culture that allows people to be more open and demonstrate that they're doing the right thing," Croteau said.
The Indiana Department of Health was expected to approve a rule Wednesday that will require hospitals to publicly report various types of mistakes to the state, a change that was expected even before Saturday's deaths. The first round of data was not expected until 2007.
Michael Cohen, president of the Institute for Safe Medication Practices, said Methodist's error could happen at any hospital with similar medication systems.
Clarian was one of thousands of hospitals nationwide that participated in the 100,000 Lives Campaign aimed at reducing lethal mistakes and breakdowns in care to prevent unnecessary patient deaths. Earlier this year, the leaders of the campaign said hospitals had prevented 120,000 deaths in the past 18 months by changing procedures.
Cohen said even with error reporting, it can be difficult for consumers to determine what mistakes mean.
"The public shouldn't see it as a scorecard," Cohen said. "You can't draw conclusions that one hospitals is any less safe than another."
Making Great Strides with the Insurance Industry
Sorry Works! is making great strides with the insurance industry, but we want to do even more and we need your help!
Sorry Works! spoke at Crittenden's Annual Conference in May (and they gave us a nice plug in their recent newsletter), and we also spoke to APMC insureds in Dallas, TX last fall. This fall, Sorry Works!will be the keynote at the 2nd Annual Medical Malpractice Insurance ExecuSummit on November 9th in New York City (for more information, contact: agenda@execusummit.com). That same afternoon, Sorry Works! will also be speaking to Physicians' Reciprocal Insurers 6th Annual Education Conference in New York City.
We are making great progress, but we want to do more. Many insurers have signed up for the Sorry Works! newsletter and are studying the issue of disclosure/early offer compensation closely. To continue pushing the needle, med-mal insurers need to hear from their customers: doctors and hospitals. We encourage doctors and hospitals to write, call, and e-mail their insurers with information about Sorry Works (send them this newsletter, forward them a link to our website). Ask your insurer to study how to implement a disclosure program.
Physicians and hospitals communicating their interest in disclosure is critically important. So often we hear from insurers the following: "Sorry Works! is great, but the docs and hospitals will never go for it." Then, we hear from doctors, "We really like Sorry Works, but the insurance company calls all the shots, and their attorneys and executives will never go for it."
Hmmmm....what we need here is a little communication. Docs need to tell insurers they want Sorry Works!, and insurers need to begin educating their insureds on the value, importance, and how-to of disclosure. And we at Sorry Works! stand ready to help with presentations and teaching programs. For more information, contact us at 618-559-8168 or doug@sorryworks.net. Thanks!
Question and Answer
We get questions all the time from you, our readers, and from this point forward we will begin sharing some of these questions and our answers. If you have a question you would like answered, e-mail to doug@sorryworks.net.
QUESTION: I have a specific question as to what exactly your organization is advocating in terms of the timing of disclosure. There is a slide (in our Power Point presentation) posted (on the website) called "Program description," where it notes that the root cause analysis may take weeks to months, and that on the basis of that analysis, one decides whether the standard of care was met and then discloses accordingly. It strikes me that there are situations where even from the get go you know the adverse event was due to error, eg, wrong site surgery. At this point in time, that would consistently fall below the standard of care. Can you advise as to timing of disclosure? It seems unreasonable to wait a few weeks for the details, when the injury is so blatant. I would appreciate your insights. Thanks.
ANSWER: You are correct.....cases where gross/obvious errors happened events need to move a little more quickly; however, not too quickly. After an obvious error (say wrong side surgery as you reference) the patient/family needs to know that an error happened, you are sorry, you/your staff are going to investigate what happened and let them know, and for the patient/family not to worry that you will take care of the problem. Give them your contact information and answer any calls or inquiries for information quickly and friendly - don't give them any reason to suspect a cover-up.
You still need to do an investigation to find what exactly happened, how the mistake occurred, and how the problem(s) will be fixed so the error doesn't happen again. After you have gathered this information, re-contact the patient/family to tell them you want to schedule a meeting. Also advise them to retain an experienced med- mal attorney (if they wish - not required, but they should be instructed to do so). In the second meeting, you will explain everything that happened, admit fault, apologize, and offer upfront compensation (which could include waving all current and future bills, helping out with expenses for the patient/family, and, yes, writing a check for a settlement offer).
To determine a fair settlement offer, you will need to engage your insurer and risk management team and develop a fair offer, knowing full-well that the patient/family and their attorney will usually ask for more, so your offer needs to developed with room for negotiation (i.e, you'll offer $10K, but you can really live with $15K - follow?).
Communication is important - very important. After any adverse event (whether error is clear or not) you must make that initial contact with the family, let them know you are investigating the situation, will get back to them, and provide your contact information. You do this to avoid any suscpicion of a cover-up. Then, after your investigation is complete, you meet with the family and their legal counsel (if they wish) and share the results of your investigation and potential next steps. Communication and maintaining relationships and trust are the name of the game.
Again, if you have questions, please e-mail them to doug@sorryworks.net.
The Pope's "Apology"
What folows is not intended to be a commentary on religion and/or endorse or support any particular religion or religious beliefs. Instead, this section is simply highlighting recent events in the world of religion to teach a lesson about effective apology.
Pope Benedict recently apologized for his unfortunate remarks about Islam - and he missed.
Just like physicians who don't intend to harm patients, the Pope never intended to insult followers of Islam, but he did. Of course, the Pope's remarks in no way should have led to the many acts of violence. However, as the Chicago Tribune penned in an editorial yesterday, "It's not hard to see why many Muslims would take grave offense."
So, an apology was needed to repair the damage, remove the anger that fueled the protests and violence, and re-open dialogue between Christians and Muslims. Instead, the Pope said he was "deeply sorry for the reactions in some countries to a few passages in my address...which were considered offensive to the sensibility of Muslims." (source: Chicago Tribune, September 19, 2006).
This "apology" was the equivalent of a husband saying to a wife, "Well, I'm sorry you've gotten so upset about me forgetting our anniversary." Such apologies don't quell anger - they create more of it. They don't accept responsibility and blame - they throw it back on the victim.
Sorry you Muslims are so touchy, says the Pope. Uggh!!!
No wonder many Muslim leaders say the Pope's apology didn't do the job. And it's the same reaction patients and families have when doctors and medical professionals don't accept resonsibility for medical errors. People who have been wronged want to see folks take ownership of errors and mistakes. It's universal. And it's the only way healing can begin.
Here's a suggested apology for the Pope:
"I made a mistake, and I am sorry for that mistake. I never intended to hurt followers of Islam with my words, but I did. I am deeply sorry for this incident. We are all God's children and we must learn to work and live together in peace, and communication between people of different faiths in an important part of that process. Unfortunately, my comments damaged relations and communication between Christians and Muslims. For this I am sorry, I ask forgiveness from the Muslim world, and I am re-committing myself to increased and improved dialogue between our faith and the Muslim faith."
Sorry Works! at Carson City Hospital
Many thanks to our new friends at Carson City, Michigan Hospital who invited Sorry Works! to give two talks to their nursing staff and medical staff earlier this week. Special thanks to Ms. Shawn Smith, Carson City risk manager, for setting up the day.
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