What Happens When a Patient is Harmed?

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Del curso dictado por University of Florida

Fixing Healthcare Delivery

116 calificaciones

University of Florida

Fixing Healthcare Delivery

116 calificaciones

Isn’t it time to end the loss of life from preventable medical errors? Each year 100,000 patients die from preventable errors in the U.S. How can you help to change this intractable problem? Knowledge is power, and this course will provide you with a deep understanding of the problems and the solutions. You can become part of the solution.

De la lección

Understanding and Preventing Human Error Part II

This module introduces you to the famous W. Edwards Deming red bead experiment that illustrates the tyranny of random variation, and introduce the use of run charts to differentiate random or common cause from specific cause variation. Next we will introduce you the concept of reliability and will illustrate why we need to dramatically improve the reliability in health care. Strategies for reducing human errors are reviewed, and the effectiveness hierarchy of different interventions discussed. We end with a discussion of how health systems and providers should be treating patients and families who they have inadvertently harmed.

Understanding and Preventing Human Error Part II Overview2:27

How Do We Know if a Change is an Improvement, Part I4:04

How Do We Know if a Change is an Improvement, Part II3:37

How Reliable is Healthcare?7:25

How Can We Reduce Human Error?10:49

What Happens When a Patient is Harmed?6:55

Conoce a los instructores

Frederick S. Southwick, MD
Professor
College of Medicine

What happens when a patient is harmed?

Because our systems are defective, patients have been and

will continue to be harmed.

100,000 deaths and 1 million injuries are due to preventable errors each year.

How are these acknowledged harmful errors being managed?

Is our present malpractice system effectively addressing

this important issue?

How should doctors, nurses and administrators respond?

What should patients expect?

Can we do better?

Let's look at the case of Georjean.

She underwent robotic assisted laparoscopic surgery to remove her kidney,

that contained a large noninvasive tumor.

The good news is, the surgery cured her cancer.

But the bad news is, the surgeon nicked her bowel causing a bowel leak.

Immediately following surgery, she began experiencing severe abdominal pain.

Despite her loud complaints, the doctors and

nurses minimized her symptoms until her blood pressure dropped.

She had developed septic shock, a condition that is often fatal.

She told her husband, goodbye, I know I'm going to die.

Georjean was rushed to the operating room

where they found the accidental cut in her bowel.

Bacteria had poured out of her bowel causing multiple abscesses or

collections of pus.

The surgeon washed out the bacteria and the pus and

placed multiple drainage tubes.

Her septic shock was also complicated by respiratory failure

requiring respiratory support.

And she remained in the intensive care unit for 20 days.

After a short discharge, she returned to the hospital because of eight

newly formed abscesses that required the placement of new drainage tubes.

Prolonged antibiotic treatment and a two-month hospital stay.

Her wounds took six months to finally heal and

she was left with multiple abdominal wall hernias.

She lost her job and

then she lost her insurance as a consequence of her prolonged illness.

And what did the surgeon who caused this preventable

error in the hospital system do?

Nothing.

She received no financial support.

She was abandoned by her physician when she lost her insurance.

She continues to wear a binder to keep her bowel from pushing

out through her hernias.

And she can only eat small meals.

Is this the way injured patients should be treated?

I do believe all of you can sympathize with Georjean's plight.

Many of you would recommend that she hire a lawyer to file a malpractice suit.

But the threat of a lawsuit quickly creates

a wall between injured patients and caregivers.

Caregivers explain the reticence to speak with patients saying, I'm afraid to talk,

because anything I say will be used against me.

Studies have shown that the irony of this claim is that when caregivers

fail to explain and create a wall of silence, patients are more likely to sue.

Why do patients sue?

They are angry.

They want to discover the truth, they want a sincere apology,

they want to prevent the same thing from happening to others.

And often, like Georjean, they need financial support, they can't work.

How often does our present malpractice system serve the harmed patients

best interests?

Only 2% of patients harmed by medical errors sue.

If they win, patients and families receive only 45% of the winnings.

Despite it's ineffectiveness, our malpractice system has been estimated to

cost an unbelievable $150 billion.

Is there a better way?

A respected lawyer, Rick Boothman, set out in 2001 to find a better way.

Working at the University of Michigan,

he ended the adversarial approach of deny and defend.

He felt that this approach was unethical and

was not in keeping with his academic medical center's mission.

And he also determined that this approach undermined their patient safety programs

by encouraging secrecy rather than transparency.

How could anyone learn from their errors if they were shoved under the rug?

In place of this outdated and unethical approach,

he promoted open communication and counseling.

Patient harm can be reported 24/7 at the University of Michigan.

And the representative responds within 24 hours and immediately offers counseling.

The representative stays in contact with the family until their claim is settled

providing continuity and maintaining open communication.

There is honest and rapid investigation which usually takes less than 30 days.

When a preventable error has occurred, a sincere apology is offered.

Based on the root cause analysis or RCA, a plan to prevent the error from

recurring is presented to the hospital and to the family.

When preventable harm occurs, fair financial compensation is offered

that is based on the calculation of an experienced insurance adjuster with

the supervision of the patient's legal representative.

What happened when this program was implemented?

From 2001 through 2007, how does it compare to prior

to its implementation, 1995 to 2001?

Claims dropped by 46%, malpractice suits dropped by 65%.

Liability costs decreased by 59 percent.

Legal fees dropped by 61 percent because lawyers billed at an hourly rate.

Because they could not request a contingency arrangement,

because the healthcare system admitted their guilt.

Time to resolution decreased from 1.36 to 0.95 years.

Shouldn't patients expect their warranty for their care?

After all, automobile companies are now offering 100,000 mile warranties.

Even auto mechanics offer a six month to one year warranty on their repairs.

Why not healthcare?

Don't health systems and caregivers have a moral obligation to help those they harm?

Shouldn't every healthcare system follow the example of the University of Michigan?

Thank you.

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