Becker's Hospital Review

93 FINANCE CMO / CARE DELIVERY COVID-19 cluster at Brigham and Women's tops 50 cases; hospital cites inconsistent PPE By Gabrielle Masson B oston-based Brigham and Women's Hospital as of Oct. 6 reported 52 COVID-19 cases tied to an out- break affecting two inpatient units. As of Oct. 6, 39 employees and 13 patients have tested positive for the virus. No new patients have been infected since Sept. 30, according to the hospital. Since Sept. 25, 7,250 employees have taken 8,544 COVID-19 tests. All current inpatients have been tested and will be tested every three days. Patients are also tested upon admission. Visitors are still allowed in some areas of the hospital. The hospital is still investigating how the virus spread, but listed the following contributing factors: • Many patients weren't masked while interacting with staff • Providers were inconsistent in their use of eye protection during patient encounters • The first patient to test positive had received an aerosol-gen- erating procedure prior to the positive test result • A staff member with mild symptoms, consistent with histori- cal seasonal allergies, continued to work • Lack of physical distancing among staff while unmasked while eating n 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 te- nets of this process, aligned with hospitals' ef- forts to build a culture of safety and continual 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 pres- ident of ambulatory care and clinical services for Oakland, Calif.-based Kai- ser 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 effectiveness at Stanford (Calif.) Healthcare Question: What are some common pitfalls or things hospitals should avoid in the aftermath of an error? Dr. Nirav Patel: We had an event where there was an eagerness to disclose the wrong er- ror. 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 fami- ly 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 reason- able, 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 com- plication, and the person's fine, so no wor- ries." 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 some- thing that could've been done better?" Hav- ing a mindset of pursuing perfection 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 in- crease 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 under- stand the actual problem. Failure modes and effects analysis 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 immediate 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 ac- tually 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

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