Hot Potato Idea! Involving Families in RCAs
Over the last few years, Sorry Works! has regularly encouraged healthcare, insurance, and legal professionals to include formal interviews of patients/families as part of the review of any adverse medical event. At the minimum, letting a family tell their story and feel heard can be an incredibly empathetic act. However, family members are usually the only constant in the care continuum, and more than ever they are taking detailed notes at the bedside. Don't you want to know what is in the family's little black book? Any lawyer will be interested in seeing the little black book. Indeed, no review is complete until the family has been interviewed!
Today, I have invited prominent patient safety advocate Dan Ford to share his perspective on including families in the RCA process. Dan not only shared his written thoughts below, but he also provided us with a picture (see above, right) he frequently uses in his presentations to symbolize how patients and families are shut out of the review process. The floor is yours, Dan....
Involving Families in RCAs
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With medical errors now considered the third leading cause of death, we need to do everything possible to make medicine safer. For fourteen years I have been doggedly persistent in encouraging providers to invite the patient/family to participate in their RCA's (Root Cause Analysis) - data gathering, analysis/discussion and recommendations for the future -- following a sentinel event/preventable harm.
It is a hot potato! Providers and attorneys are resistant. I believe this transparent approach will help reduce medical errors. We can learn from patient involvement. It will facilitate healing by all involved, help the business case, and is the right thing to do.
The key word is invite. Not all should be invited. Not all will accept the invitation. It needs to be the actual patient/family member involved, not a representative of the patient population. That would not serve the same purposes.
The reason for recommending RCA involvement is because of a multi-medical error tragedy experienced over seven months in 1991 by my first wife, Diane, in a hospital in the suburbs of Chicago....none of which should have happened....and much related thought over the years. Here is the series of events leading into my recommendation:
· At age 47, Diane went into the hospital for a hysterectomy....routine, as it was called.
· Her colon was cut (ERROR), an emergency colostomy performed.
· Twelve hours later back in her room starting recovery, she overdosed on morphine from her PCA pump (ERROR).
· NARCAN was not available in the nurses' station (if not an ERROR, a very poor/low standard of care at the time in that hospital).
· Code team responded from the ER right away, took over 21 minutes to intubate her, causing a respiratory arrest (ERROR). She experienced permanent brain damage/permanent short term memory loss.
· Two months later, back into the hospital for another surgery to reconnect her colon....successful, as described at the time. She never remembered why she had the bag, or how to clean or change it.
· Back in the hospital five weeks later with a kinked colon (ERROR). Fortunately, no surgery, colon straightened itself out after drinking much GoLYTELY.
· Back in the hospital a few days later because of bowel seeping into her vagina. The doctors speculated a fistula was caused by a bowel or stray staple from her colon repair.
· The fistula did not heal on its own, so another surgery was conducted three months later (caused by ERROR)....her fourth hospitalization and fourth surgery. It was successful.
· The doctors came out and almost gleefully told me they found the cause of the fistula....staples....foreign objects left in her body after her colon repair (ERROR).
· NONE of these errors should have happened. The quality of her life is not good. She lives in an independent living facility. She has a masters in education, was working on her second masters when this tragedy happened. Her passion was to become a hospital chaplain. Tragically, her ability to learn was gone in a matter of seconds.
· I asked for a copy of her medical record: "Yes, take a check for $94 to medical records, and you can get a copy." Was chintzy....bit my tongue for the moment.
· I asked for a copy of the committee report on debriefing her multiple medical errors in their hospital: "No, that is confidential!" I asked again, noting she had permanent brain damage, would never work again: "The answer is still no....it's confidential." That interaction is probably the reason for my now 14 years of patient safety advocacy. It was terribly offensive to be told it was confidential, with all Diane experienced! Not only did Diane experience life-long brain damage, but this wall compounded the entire tragedy.
· My risk manager interaction/attitude was troublesome and jerk-like at best.
· Nine year medical malpractice lawsuit.
· What happened to Diane and our family was devastating....and cruel. It was made more cruel by how we were treated, including keeping us out of the debriefing process. That is not hard for honorable/professional risk managers to understand, but their hands are frequently tied by the powers that be. They are the only ones in the entire organization to learn all of what happened, and what can be done for the patient/family who have experienced such harm.
· ASHRM asked me to serve on a patient safety committee and encouraged my advocacy (2002/03): "Too many people are dying and injured from medical errors. Providers need to hear Diane's story, Dan." The other catalyst for my advocacy was the denial of the committee report that debriefed her medical errors, especially her permanent brain damage.
· During my first patient safety presentation in 2003, and since, I encouraged providers to invite patients/family members to participate in their RCA's. I have long felt that if hospitals promote patient centered care, partnership with patients, transparency, and really care about patients/families following medical errors that happen while under the care of their hospital/physicians, it is disingenuous to leave them out of their own RCA.
BENEFITS TO INVITING THE PATIENT/FAMILY:
· Break down walls, or prevent walls from being built, following sentinel events/preventable harm.
· Learn from the patient, the one constant thread in the entire patient experience....sometimes also family members. They are mindful, pre-occupied with failure, noticing the unexpected and not concerned with political correctness. Mindfulness is crucial in a High Reliability culture including, in my opinion, being role modeled by patients.
· Contribute to medical error reduction.
· Good business. People typically sue because of the way they are treated.
· It's the right thing to do, even though awkward for all involved.
· Raises the bar for true patient-centered care, partnering, respect and transparency.
· Contribute to a Just Culture. Patient/family can validate caregiver behavior, if/when caregiver behavior is questioned, or challenged, or bullied by ego's.
· Patient demonstrates leadership when her/his comments/suggestions are pertinent/constructive.
· Contribute to healing, among the key players involved. The patient/family member may demonstrate caring if/when they comfort/console a provider involved in the event/RCA that is overcome with grief.
· Legal counsel/provider resistance. Fear is the most significant barrier, fear of the unknown. Fear of lawsuits. Transparency and honesty and extending the invitation to patients to participate in a genuine way will help break down these perceptions,
· Sometimes it just takes backbone, courage and a willingness to be vulnerable by the CEO, CMO, board chair or even the clinicians involved, to tell legal counsel and reticent physicians: "We respect your recommendation not to do this, but this time we are inviting the patient." And the next time, and the next time....until it becomes a best practice.
· Some patients/families are opportunistic, just want to sue, should not be invited. However, most want to see that it never ever happens again to anyone.
· Some physicians decide it would be too emotionally difficult for the patient/family to be involved....sooner or later. That is ONLY the business/concern of the patient/family member. This is condescending by physicians, even when well-intentioned.
· Not living our values according to our TRUE NORTH. This quote from C.S. Lewis would seem to apply: "Education without values, as useful as it is, seems rather to make man a more clever devil."
The entire tragedy experienced by Diane and our family and provider behavior following was needless. Human nature got in the way, got scared, lacked the willingness to take risks and talk to us about/involve us in discussion about the committee report.
I am optimistic we can do this and do it constructively. It seems like common sense to me. We need more brave souls willing to do this. I will work with any provider to change behavior to make this happen!
I want to thank Dan for sharing his story and his thoughts. So, what are you thoughts? Please contact us...