Guidelines for disclosing

unanticipated events

Heather H. Sveadas

Director of Risk Management/ Associate General Counsel Erlanger Health System

Dr. Alan Kohrt

Assistant Dean Faculty Development

UT College of Medicine

Healthcare Principles in Practice

July 14, 2020

UT College of Medicine Chattanooga

Disclosure & Apology – The

Erlanger Way

Something bad happens:

Ex: Patient given wrong medication, wrong site

surgery, etc.

What Do We Do?

• The Old Model – “never say you’re sorry”

Deny & Defend

Categorically reject fault for adverse events/outcomes

Complex medical & emotional issues become the

lawyer’s turf

Patients are kept in the dark

Deny & Defend Continued….

• Patients feel abandoned

• Lack of trust

• Patients turn to lawyers for help

• Attorneys for both stonewall the patient. Focus

on winning.

The Impact of Deny &

Defend:

1. Litigation takes an emotional toll on physician and

patient/family;

2. Chills communication btw physician and patient;

3. Patients have a natural desire for justice and

accountability---lawsuit is the only way;

4. Patients feel compelled to protect others; and

Biggest Problem with Deny &

Defend

Systematically justifies substandard care. Disregards

ongoing risks faced by patients.

Erodes the patient/physician relationship of TRUST

The New Way: Early

Resolution

• Erlanger changed the way it handles adverse

events.

• Early Disclosure & Resolution

• Promotes patient safety through honesty,

transparency & accountability.

Why Change:

1. Honesty is paramount for safety improvement; and

2. Short term financial risk focus prevents long term

improvement.

3. It’s the right thing to do…….

Erlanger’s Priorities:

1. Open communication with patients about adverse unintended outcomes.

2. Reduce future injuries and claims through reporting, investigating, mitigating and correcting

3. Compensate patients fairly when inappropriate medical care causes injury.

4. Vigorously support healthcare providers when appropriate care is provided.

Reporting a Safety Event:

Is it safe to report an “event”?

YES! – eSafe is a non-punitive system

Why is it a safe, non-punitive,

way to report?

Tennessee Patient Safety & Quality Improvement Act – 2011

Expanded legal protections: (1) privilege from discovery, and (2) immune from liability

What Happens When I Report ?

1. Reports are screened and reviewed;

2. Action may be taken based upon report;

3. All reports and the action taken are confidential;

4. Trends are noted.

Person who

entered eSAFE

Program Director

and

Nurse Manager,

Administration

Quality

When to Disclose?

When an adverse event reaches the patient,

regardless of whether it harmed the patient.

Patients want:

Full disclosure in a timely manner

An understanding of what happened

Expression of sympathy

They want to know what is being put in place to

prevent the same thing from happening in the future.

RECEIVE EMAIL CASE IS CLOSED Nurse MNG,

Program Director

can review in eSAFE

Why Disclose?

Strengthens the patient-physician relationship, and promotes trust.

Patients are less likely to pursue litigation if they perceive the event

was honestly disclosed

Disclosure is associated with higher ratings of quality by patients

Decrease in malpractice suits and the avg. settlement amount when

suit is filed.

(Data from ACOG –

2016 Opinion)

Barriers to disclosure:

Fear of retribution for reporting an adverse event

Lack of training

Culture of blame

Fear of lawsuits

To reduce concerns:

• Written policies/protocols that address how to

manage adverse events.

• A commitment by providers and healthcare

institutions to establish protocols to help patients,

families, providers and staff deal with difficult

situations.

• Promote a just culture that focuses on system

errors and addresses the causes of human error.

Timing of Disclosure: (Timing

varies with circumstances, but…)

• As soon as reasonably possible and

• within 24-48 hours of a practitioner’s discovery of the

Adverse Event if adequate information is available.

• Why? When patients are aware of or suspect an

Adverse Event, more time before Disclosure may

increase the patient’s anxiety and decrease their trust

in the providers and management.

Where to Disclose:

When possible meetings should be:

• In person

• At a location and time of the patient’s preference

• In a private area to maintain confidentiality, and

• In a space free from interruptions.

How to Disclose:

It is essential during any Disclosure discussion

that speculation, opinion, or attributing blame

does not occur.

Stages of Disclosure

Disclosure is often a dialogue over time; generally

occurring in two broad stages:

1. Initial Disclosure

• Initial discussion with the patient should occur as

soon as reasonably possible after the event.

• The Disclosing Physician leads the discussion

except when the Disclosing Physician and a hospital

representative decide that it is more appropriate for

an administrative designee to disclose.

Initial Disclosure Cont’d.

• Focuses on the patient’s current medical condition.

• It is primarily the responsibility of the providers, although Erlanger

administration may provide advice or assistance as needed.

• The minimum number of EHS participants will attend. Who to

include will be decided on a case-by-case basis. The patient and/or

family may have input regarding who attends the meeting.

Initial Disclosure Cont’d.

• Risk Management and Legal Services will not be

included in the Disclosure meeting.

• Tape recording of the meeting is not permitted.

Initial Disclosure Cont’d.

• Explain the facts of the event and/or harm known at the time.

• Explain the steps taken and the recommended options and

decisions in the ongoing care of the patient (e.g. changes to

care plan as applicable).

• Apologize by expressing sympathy or regret for what

occurred (“I am sorry this happened”).

Initial Disclosure Cont’d.

• Give a brief overview of the investigative process that

follows.

• An offer of future meetings, including key contact information.

• Time for questions and answers.

• Avoid speculation, opinion, or attributing blame. Provide

emotional/ practical support for the patient.

Stage 2. Post Analysis

Disclosure:

Ensure event is entered into Erlanger’s electronic

incident reporting system (eSafe) so event is analyzed

through proper channels.

The eSafe report generated results in a quality review

and analysis of the Occurrence. The analysis may

identify additional facts and reasons for the event.

RECEIVE EMAIL CASE IS CLOSED Nurse MNG,

Program Director

can review in eSAFE

RECEIVE EMAIL CASE IS CLOSED Nurse MNG,

Program Director

can review in eSAFE

Post Analysis Discl. Cont’d.

• Erlanger administration, in consultation with providers,

determines what additional information to disclose to the

patient/patient representative.

• Legal/Risk provides advice on how much additional

information to provide the patient/patient representative,

considering applicable law.

Post Analysis Discl. Cont’d.

• Continue providing practical/emotional support, if needed.

• Reinforce or correct information provided in previous

discussions.

• Provide additional facts as they are available.

Post Analysis Discl. Cont’d.

• If applicable, and when all facts are established, a further

expression of regret that may include an apology, as

appropriate.

• Describe system improvements made due to internal

analysis of the Adverse Event, if applicable.

• Avoid speculation, opinion, or attributing blame

Documentation:

• The Disclosing Physician(s) will document each

discussion including Disclosure of an unanticipated

outcome or Event.

• Time, place and date of the meetings;

• Identity of all attendees;

– The medically significant facts disclosed; and

– Next steps or changes in treatment that were discussed.

Other Considerations:

1. Call Risk Management & consider calling

insurance carrier;

2. If you need help deciding on best course of action,

call risk management for guidance.

3. If you need counseling, feel depressed, talk with

you program director or call the Dean’s office

eSafe: Second Victims

Second victims are health care providers who are

involved in an unanticipated adverse patient event,

in a medical error and/or a patient related injury

and become victimized in the sense that the

provider is traumatized by the event. Frequently,

these individuals feel personally responsible for the

patient outcome.

• Confidential – Free: Counseling

Services, Individualized Wellness

Resources, Health Advocacy,

Online Resources, Legal and

Financial Consultations, Virtual

Concierge Services.

• Call - 1.800.327.2255 (Company

ID: 8665 if asked).

• You can also use the

website: www.nexgeneap.com

• Confidential LifeBridge LINE: 423-

591-9830

• https://www.lifebridgechattanooga.

org/

• Access a Counselor:

https://www.lifebridgechattanooga.

org/counselor-bios

QUESTIONS?

Heather H. Sveadas Dr. Alan Kohrt

Director of Risk Management/ Assistant Dean Faculty

Associate General Counsel Development

Erlanger Health System UT College of Medicine