Becker's Clinical Quality & Infection Control

20 PATIENT SAFETY 4 common pitfalls to avoid after a medical error By Mackenzie Bean H ow healthcare organizations respond to medical errors has greatly evolved in the last few decades. Transparency and accountability have emerged as key tenets of this process, aligned with hospitals' efforts to build a culture of safety and continu- al clinical improvement. A panel of oncology leaders discussed the best and worst things one can do aer a medical error during a Sept. 10 session at the Becker's Clinical Leadership Virtual Event. Panelists included: • Camille Applin-Jones, RN, vice president of ambulatory care and clin- ical services for Oakland, Calif.-based Kaiser Permanante's Northwest market • Nirav Patel, MD, CMO of University Medical Center New Orleans • Teri Sholder, chief quality officer of Hospital Sisters Health System in Springfield, Ill. • Lisa Schilling, RN, vice president of quality, safety and clinical effec- tiveness at Stanford (Calif.) Healthcare Here are four excerpts from their conversation, lightly edited for clarity. Question: What are some common pitfalls or things hospitals should avoid in the aermath of an error? Dr. Nirav Patel: We recently had an event where there was an eager- ness to disclose the wrong error. What happens is that we want to be very transparent. We want to support the family. However, the error we disclosed was not what had happened. A totally different mistake had been made. at's even worse for the family when you have to go back to correct that. ey're trying to process the first event in the first disclosure, and now they feel like, "Well, you're changing the story. ere's a cover-up. ere's something else." I think it's important that the disclosure occur, but that a reasonable, fair investigation is also performed to assess what is the true error that has occurred. Lisa Schilling: One of the worst things you can do is just say, "Well, that's a known complication, and the person's fine, so no worries." Brush over it. I personally appreciate the physician leaders who will say, "at should just never happen, and even though it's known to happen, let's just figure out how we can prevent it next time." I had one physi- cian leader once say, "Giving people blood is a trigger for harm, so why did you have to give somebody a unit of blood? Was there something that could've been done better?" Having a mindset of pursuing perfec- tion rather than dismissing something that happened is important. Camille Applin-Jones: Another tendency we have as clinicians or healthcare leaders is to want to immediately solve the problem. We make an assumption about the error and then quickly apply a solution to that assumption. at can actually create more errors and increase failure and reduce morale for your people. It's really essential to be clear about what the problem is and then solve for that. I would encourage everyone not to have a knee-jerk reaction, so to speak, back to Dr. Patel's points about really completing the root-cause analysis to ensure that we understand the actual problem. Failure modes and effects anal- ysis is another great strategy. It's also important to enlist the feedback of those who were engaged in the error to begin with as part of the problem-solving, which is a step that is sometimes skipped. Teri Sholder: I totally agree, Camille. People tend to want that immedi- ate resolution. You have the algorithm in place, but it's human nature to just want to jump to, "Oh this is this outcome, or this is that outcome," when actually walking through that algorithm is the very thing that makes you question, "Well, wait a minute, could it have been this?" It just brings other variables to light, and a lot of times you'll find that it really was a system problem. n Nurse sues Kindred Healthcare, alleges retaliation for his patient safety complaints By Mackenzie Bean A nurse sued Louisville, Ky.-based Kindred Health- care in August, alleging the organization fired him in retaliation for raising patient safety concerns, reported the San Antonio Express-News. Sean Kinnie, RN, worked as an intensive care unit nurse at Kindred Hospital-San Antonio. Mr. Kinnie claims he was suspended twice and then fired after leaders at the 59-bed transitional care hospital learned he anonymously reported patient safety concerns to The Joint Commission in November 2019 and January. Mr. Kinnie said issues related to inadequate staffing and unsanitary care environments put patients in "grave dan- ger," according to the lawsuit. He also said the hospital created a culture in which employees were afraid to stand up for patients for fear of retaliation from management. In January, Mr. Kinnie told the hospital's chief clinical officer Sharon Danieliewicz that he was the staff member who reported the patient safety concerns to The Joint Commis- sion. Mr. Kinnie claims he faced increased scrutiny after this disclosure and was ultimately fired Feb. 24 for violating facility policy. Administrators told him he was let go for drawing a "culturally insensitive" image on his clipboard, which Mr. Kinnie denies. "We deny and plan to vigorously defend ourselves against the allegations contained in the lawsuit," Kindred Hospital-San Antonio Market CEO Abiola Anyebe said in an emailed statement to Becker's. "Otherwise, we are not at liberty to comment about pending litigation." n

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