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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 2 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 3 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 PARTNERING TO CREATE THE SAFEST HEALTHCARE SYSTEM 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 PARTNERING TO CREATE THE SAFEST HEALTHCARE SYSTEM 5 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). PARTNERING TO CREATE THE SAFEST HEALTHCARE SYSTEM 6 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 PARTNERING TO CREATE THE SAFEST HEALTHCARE SYSTEM 7 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 PARTNERING TO CREATE THE SAFEST HEALTHCARE SYSTEM 8 HIROC has developed a checklist to assist subscribers with managing multi-patient events 9 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 10 HIROC has developed scripts/letter templates for the following types of multi-patient events: • Infectious disease outbreak • Sterilization failure • Diagnostic errors • Privacy breach 11 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 PARTNERING TO CREATE THE SAFEST HEALTHCARE SYSTEM 12 Case Studies 13 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 14 Voting Questions 15 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. PARTNERING TO CREATE THE SAFEST HEALTHCARE SYSTEM 16 Voting Questions 17 “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 18 Annette Down [email protected] 416-730-2602 [email protected] 19 Polly Stevens [email protected] 416-730-3075