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March 24, 2009 NEWSLETTER
Doug Wojcieszak, Founder & Spokesperson
Contact phone/e-mail address: 618-559-8168; doug@sorryworks.net
THIS WEEK'S EDITION:
Reminder: Registration Deadline Nearing for Teaching and Implementing Disclosure Audio Conference, April 9th, 1pm EDT
Questions from the road
Boston Hospital Apologizes
Sorry Works! Visiting Your Neck of the Woods?
REMINDER: REGISTRATION DEADLINE NEARING FOR TEACHING AND IMPLEMENTING DISCLOSURE AUDIO CONFERENCE; 1PM EDT ON APRIL 9TH
The registration deadline is drawing near for the April 9th audio conference on teaching and implementing disclosure. Click here for registration information: http://www.sorryworks.net/pdf/audiosw2.pdf.
How do you teach disclosure & apology to your staff and how do you implement disclosure are hot questions in healthcare today. The Sorry Works! Coalition and Stevens & Lee are proud to offer an audio conference "case study" which will provide listeners with insights into how the University of Illinois Medical Center launched a disclosure program and how they train their staff, residents, and students on disclosure & apology.
The disclosure & apology program at the University of Illinois Medical Center has been operating successfully in the tough litigation venue of Cook County, and their successes have been featured recently in the New York Times, Chicago Tribune, and many other prominent popular and trade publications. In fact, the UI's disclosure program has become a model for other hospitals and insurers to follow and the program's leaders are sought-after speakers. Now you can hear them live in your own office or conference room. Join the audio conference to learn how UI leaders launched their program and hear about the successes they are experiencing. Also, listen in to hear how they train staff, residents, and students on disclosure and apology principles. Indeed, this is a "can't miss" audio conference for all parts of the medical/hospital community, including medical school faculty and personnel.
The speakers for the event include Dr. Tim McDonald, MD, JD, Chief Safety and Risk Officer for Health Affairs at the University of Illinois, and Dr. David Mayer, MD, associate dean for curriculum, director of cardiothoracic anesthesiology, and co-director of the Institute for Patient Safety Excellence (IPSE) at the UIC College of Medicine. CME credits will be provided for attendees of the conference.
You can access registration form by clicking on this link: http://www.sorryworks.net/pdf/audiosw2.pdf.
Thank you and we look forward to you joining us April 9 at 1pm EDT.
QUESTIONS FROM THE ROAD
Two weeks ago Sorry Works! made presentations to physicians, business managers, and attorneys for an Indiana risk-retention group (RRG) as well as members of the Connecticut Hospital Association. Great presentations, and some great questions from the audiences below we want to share with you.
Interested in a Sorry Works! presentation? Contact doug@sorryworks.net or call 618-559-8168.
Question #1:
"In your step one of the disclosure process, after saying 'I'm sorry this happened,' and promising a quick, thorough investigation to learn what happened, you encourage us to offer food, lodging, transportation, phone calls, etc as a form of support and good customer service to the upset family. But, as a physician I don't have the authority to obligate my hospital to pay for a night a local hotel, reimburse cab fare, or even provide meal vouchers in our cafeteria. What do I do?"
Answer #1:
We have worked with many organizations who have asked the same question. I will give you the benefit of my experiences. Some organizations deal with this issue by ensuring that the physician first get approval from the hospital risk manager, in an expedited fashion. Others have incorporated this into their disclosure or post-adverse event communication policy. We recommend that an organization determine in advance, as part of its policy, a dollar amount that the hospital will approve for situations like this, with no questions asked. Most hospitals have used a value up to $100 or $250. Having this in your policy can side-step much of the administrative process involved with such a request and employees on the front-line will appreciate this ability and certainly it would be cherished by the patient and family! It helps to minimize anger that can be developed when patients and families become frustrated post-adverse event. At the minimum, great evidence will be produced for a solid defense!
Question #2:
"In step one of the disclosure process, you encourage us to only empathize and offer good customer service, while staying away from fault-based apologies until after an investigation has proven that a mistake occurred. As a surgeon, it strikes me as a little disingenuous - and possibly likely to increase anger with patients/families - that if I know I made a mistake not to admit fault right there and then, instead of waiting 48 hours - or longer - for some investigation to validate what I already know."
Answer #2:
Great question....again, we encourage caution. Yes, you may have made a mistake, but whether you legally made a mistake which was an action that fell below the standard of care and caused injury (medical malpractice) is an entirely different issue. Often we are contacted after the fact, when a physician, in the heat of the moment, hastily indicated he had done something wrong. Please understand, once you ring the apology bell, you can’t back track! There is nothing wrong with explaining the facts of what is known at the time, empathizing, promising an investigation, and reporting back to the patient/family within a reasonable period of time. That's credible, and most patients, families, and plaintiff's attorneys will understand the need to get the facts straight.
Even in those cases of gross malpractice - say a wrong-side surgery - you usually don't know all the facts immediately. Sure, you can say to the patient/family a mistake has occurred, because they know a mistake has occurred! However, be slow to accept or assign blame. Many reasons may account for the wrong-side surgery - and it may not be you!
BOSTON HOSPITAL APOLOGIZES
Great story we learned about over the weekend - read below! Please share with colleagues and friends.
Baby OD trauma; Newborn OK after morphine gaffe at BMC
By JESSICA FARGEN
21 March 2009
Boston Herald
First-time Medford parents are breathing a sigh of relief as their newborn daughter recovers from a scary medication mistake at Boston Medical Center that resulted in their bundle of joy getting an overdose of morphine.
Stellina Sasso, who was born March 2, was kept under observation and put on a low dose of morphine to combat withdrawal from a medication her mother takes, her proud papa Nick Sasso, 23, told the Herald.
Sasso says his world came crashing down March 14 when he showed up to see little Stellina in her hospital room with a heat pack on her chest. He was told that a nurse had accidentally "overdosed" her with morphine.
He and his wife, Stefania Sasso, 26, still haven't brought her home.
"We don't sleep. We are too worried about what will happen next," Sasso said. "My daughter almost lost her life."
He said that although the long-term prognosis appears good, the medical mistake means Stellina will stay in the hospital for at least two more days. He said the extra morhpine made her drowsy.
"She couldn't keep her eyes open, and she was very tired," Sasso said.
Sasso said the nurse who made the mistake apologized to the family along with a doctor and offered to bring in a crisis team.
Boston Medical Center issued a statement acknowledging a medication error involving an infant March 14. The hospital staff apologized to the parents, and the hospital is reviewing the incident, according to the statement.
"Boston Medical Center takes patient care and patient safety very seriously. On Saturday, an unfortunate medication error occurred involving an infant. The hospital met with the family the same day to disclose the error and apologize," according to the statement. "The medication error did not cause an adverse outcome or change the infant's condition. An internal review of this incident is ongoing and we are taking all necessary steps to prevent a recurrence."
The Department of Public Health does not track medication errors unless the error results in serious injury or death, said spokesman John Jacob.
jfargen@bostonherald.com
SORRY WORKS! VISITING YOUR NECK OF THE WOODS?
We are in the middle of the busy Spring speaking schedule at Sorry Works! There are several speaking engagements coming up where you might be able to see Sorry Works! Check the schedule below, and if we're not in a town near you, give us a call at 618-559-8168 or e- mail doug@sorryworks.net to schedule a Sorry Works! presentation for your own Grand Rounds, hospital leadership, insurance company leadership, medical association members, etc.
Here's the schedule:
- March 30th, Costa Mesa, CA, California Association for Healthcare Quality, www.cahq.org.
- April 10th, Case Western Law School Forum, Cleveland, OH
- April 16th - New Jersey - closed evening engagement but time during day and day before (April 15th) to make additional presentations...contact doug@sorryworks.net or 618-559-8168
- April 17th - San Diego, Hospital Association of Southern California (www.hasc.org)
- April 23rd - Las Vegas, Collins Insurance Meeting (www.collins.com)
- May 4th - Tampa, Crittenden's annual meeting - we won't be speaking here, but will be attending the "Sorry Works" forum and will have a booth. Please stop by.
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