Ethics Committees and Medical Error

Carol Bayley, PhDJuly 6, 2011

Ethics Champions Program

Phone Etiquette

Press * 6 to mute; Press # 6 to unmute Keep your phone on mute unless

you are dialoging with the presenter

Never place phone on hold

Overview

What kind of problem is medical error?

What do values have to do with it? What does the Ethics Committee

have to do with this issue?

What kind of problem is it?

What kind of problem is it?

1999 IOM study: Leading cause of preventable

deaths 44—98,000 people die annually One million people injured annually Annual cost $17—29 billion

What does it look like?

Medication errors (wrong drug, wrong patient, wrong dose, etc.)

Wrong site surgery Equipment failure Inadequate skill “an accident waiting to happen”

Near Misses

Harmless Hits

Errors That Cause Harm

?

Universe of Mistakes

Combined errors

Overlapping Responsibilities

staffMD

Two Approaches

Pre-IOM report New Thinking

Joint Commission Congressional action on mandated

reporting Med-Mal insurers In our systems, values based

Old: Blame, Shame, Lie, Deny Deny the allegation; make the family or

patient litigate to get information; don’t pay a penny that a court doesn’t require. Lie if necessary, and certainly if the truth won’t bring the person back and others won’t find out.

Privately, identify the clinician (who gave the dose, ran the machine, did the surgery) and fire her. This will show the family “something was done” and will make an example for others to learn from.

New: Get to the bottom of it

Swiss cheese model Person who “did it” is the last link

in a causal chain Blame and shame shuts people up;

if you discourage people from reporting, you will never improve

Swiss Cheese (Jim Reason)

Underpinning of policies

In a values-driven organization, the values should link to behavior

“Ethics is the application of values to action”

CHW Example

Dignity Collaboration Justice Stewardship Excellence

Dignity Everyone we touch--patients, family members, physicians, other health care workers and our own CHW team members--possesses an inborn dignity as a person worthy of respect.

Honest and direct communication Prompt supply of information Advice about legal system Honest admission Everyone is different Timely and sincere apology

Collaboration: Working together with physicians and other team members is at the heart of our service to patients. We are successful because of the work of an entire team.

Atmosphere of trust, honesty, transparency

No blame Work together to solve problems Relationship with system services

for Risk Management, Legal, Care Management and Mission Integration

Justice: We treat everyone fairly and equitably

regardless of rank or status. Well-educated or not, English-speaking or not, confident in the healthcare system or not, all are deserving of fair treatment.

We take our fair share of the burden of claims, and expect the same of partners.

Primary care physicians, specialists, “friends of the hospital” and infrequent admitters.

Physicians and nurses treated equitably. We honor public accountability and

rules for reporting error.

Stewardship: We hold precious assets of CHW: our human resources, our finances, and the trust the public places in us.

We fairly compensate an injured party, even when that means expenditure of CHW funds.

We share the burden of claims fairly with those that bear responsibility for them.

We explore every avenue for a just settlement.

Excellence: Always doing better involves admitting that we are not quite “there.” With humility and determination we seek to constantly improve the systems we have so that they will not injure patients, families or caregivers.

We share information to improve safety.

We share claims information to study causes of our failures.

We structure opportunities for improvement.

What can your ethics committee do?

Informed consent education Review policies with organizational

values in mind Help organization see that policies

reveal ethical stance of organization