Download Leading Practices in Managing Multi-Patient Events

Leading Practices in
Managing Multi-Patient
Events
Risk Management Conference
27 April 2015
Polly Stevens, VP, Healthcare Risk Management
Annette Down, Senior Healthcare Risk Management Specialist
PARTNERING TO CREATE THE SAFEST HEALTHCARE SYSTEM
Topics
• Introduction to HIROC’s new guide to
Critical incidents and multi-patient events
• Overview of approach to multi-patient
events
• Case studies
PARTNERING TO CREATE THE SAFEST HEALTHCARE SYSTEM
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Leadership
• Crisis management
• Crisis communications
Patients and Families
• Disclosure
Staff
• Second victim
• Just culture
Key Concepts
•
•
•
•
Systems thinking
Complexity
High reliability
Medical malpractice
Analysis
• Interviews
Recommendations
Implementation
Reporting
• Confidentiality
Multi-Patient Events
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Multi-patient Events Defined
• Individual, or a series of
related events, that
injure or increase the risk
that many patients would
be injured because of
health care management
(Dudzinski et al, 2010)
• Commonly involve
– Infectious disease
outbreaks
– Sterilization failures
– Diagnostic errors
– Privacy breach
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Common Challenges
• The number of impacted
patients may be unknown
• Often unknown if actual
harm occurred
• Probability of harm and
severity vary; no two multipatient events are alike
• Some notifications may be
more urgent than others
• Decision on who and how to
notify must be made
carefully in a timely manner
• Resource intensive
• Documentation
management
• Media coverage
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Chafe et al. (2009)
“The organization itself
needs to be the first to
present the information
to the public.
Transparency needs to
trump concerns about
increasing legal liability.”
(p.1126).
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Dudzinski et al. (2010)
• Proactive disclosure to all
unless strong, ethically
justifiable case against
disclosure
• Disclosure obligations
greatest when the events
resulted from preventable
errors or system failures
• Obligations to patient
care, transparency and
retributive justice far
outweigh risks to the
organization
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Ideally What Should Happen
• Concern Raised
– Consider potential immediate needs
– Interdisciplinary team
– Timely notification to HIROC
• Lookback
– Timeframe
– Determine threshold for harm
– Database
• Patient Notification
– Method
– Notify
– Track notification
• Communication Strategy
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HIROC has developed a checklist to
assist subscribers with managing
multi-patient events
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Method for Notification
• Decision impacted by
many factors
– Number of potentially
affected patients, urgency,
whether testing/follow-up
is required and relationship
to care provider
• In-person notification
– Ideal if low number of
affected patients
– May be accompanied by
follow-up letter with details
and next steps
PARTNERING TO CREATE THE SAFEST HEALTHCARE SYSTEM
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HIROC has developed scripts/letter
templates for the following types of
multi-patient events:
• Infectious disease outbreak
• Sterilization failure
• Diagnostic errors
• Privacy breach
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Reporting to HIROC
• If considering (or engaged in) look back,
or, suspect a multi-patient event, notify
HIROC early on
• Immediate access to HIROC/legal/clinical
experts who can help to ensure an
effective and ethical process
• High potential for class action lawsuit
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Case Studies
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Case Study #1
• A multi-site hospital declares an outbreak of C. difficile
at one of its sites. At this time 25 patients have tested
positive, 10 patients are in hospital receiving treatment
and one patient has died.
• Two months later, an outbreak is declared at each of the
other three sites.
• Four months after the initial outbreak the hospital
realizes that 42 patients have passed away related to C.
difficile infection.
• Five months after the initial outbreak the hospital notes
that there are 102 reported cases of C. difficile across all
three of its sites; of those cases 40 are attributed deaths
where in 70% of the cases C. difficile was a factor.
PARTNERING TO CREATE THE SAFEST HEALTHCARE SYSTEM
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Voting Questions
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Case Study #2
• A community hospital became aware
through an employee and subsequent
privacy audit that another employee in
Health Information Management
inappropriately accessed 190 health
records of patients, including children and
patients with mental health issues, over
three years.
• The employee accessed clinical data
including lab tests and x-ray results.
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Voting Questions
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“As complex as serious clinical events are, many
special circumstances can make them dramatically
more complicated. At the top are adverse events
where tens, hundreds, or thousands of patients may
have been affected – major failures of the health
care system, including cases around poor sterilization
practices or contamination of endoscopic devices,
hepatitis outbreaks, interpretations of diagnostic
studies, pseudomonas outbreaks, overdoses of
radiation, and cases where it can’t be determined
how many patients were impacted.”
Conway et al 2011, p.25
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Annette Down
[email protected]
416-730-2602
[email protected]
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Polly Stevens
[email protected]
416-730-3075