Patient Safety Competencies Curriculum Development

Domain 6: Recognize, Respond to and Disclose Adverse Events

Key and enabling competencies:

1. Health care professionals who recognize the occurrence of an adverse event or close call are able to:

1.1. Define the terms harm, adverse event, close call, and the response that is appropriate to each

1.2. Distinguish between the harm resulting from an adverse event and the natural progression of the patient’s underlying medical condition

2. Health care professionals who mitigate harm and address immediate risks for patients and others affected by adverse events and close calls:

2.1. Assess the immediate safety and care needs for the physical and emotional well-being of patients and their families, and provide interventions as appropriate

2.2. Reduce or manage the risk of further harm to patients aff ected by adverse events and close calls

2.3. Provide appropriate support for individual health care professionals and teams involved in adverse events and close calls

3. Health care professionals who disclose the occurrence of an adverse event to patients and/or their families as appropriate and in keeping with relevant legislation:

3.1. Understand what information should be disclosed at the initial disclosure stage, the time frame for disclosure, and the relevant documentation, reporting, and analyses

3.2. Recognize the ethical, professional and legal obligation to disclose and report adverse events

3.4. Are aware of existing policies and procedures associated with disclosure and the extent to which these foster a culture of patient safety

3.5. Engage in honest communication and empathic dialogue with respect to disclosure

3.6. Recognize that there are situations that constitute special consideration regarding disclosure, for example, patients in vulnerable situations, patients who have a substitute decision-maker, patients with special communication requirements (e.g., those who are hearing impaired), and patients whose cultural perspective on disclosure differs from the provider’s

3.7. Understand the stages of disclosure

3.8. Determine who is responsible for the disclosure and who should be present when it is made

3.9. Recognize the role of expressions of regret and when an apology should be considered in postanalysis disclosure

3.10. Document unexpected outcomes, adverse events and the disclosure discussions

3.11. Provide ongoing follow-up as needed

3.13. Appreciate the legal implications arising from disclosure

4. Health care professionals who effectively report the occurrence of an adverse event or close call:

4.1. Recognize that the reporting of adverse events takes place across the continuum of care and includes primary, secondary and tertiary care centres

4.2. Anticipate the need to gain a better understanding of the adverse event, such as by considering what samples, clinical materials and equipment may be helpful in future investigations

5. Health care professionals who participate in timely event analysis, refl ective practice, and planning for the prevention of recurrence:

5.1. Engage in personal and professional refl ection regarding the adverse event

5.2. Recognize the importance of monitoring the outcome of event analysis

5.3. Apply lessons learned from the event analysis

5.4. Advocate for system change as warranted

5.5. Recognize the need for information exchange across health care organizations and as mandated by provincial/territorial legislation

Learning objectives:

Knowledge

1. To learn terms harm, adverse event, close call, and the response that is appropriate to each
2. To learn the professional and legal obligations to disclose and report adverse events
3. To know the difference between harm from disease vs adverse event
4. To appreciate the need for a just culture of safety in supporting disclosure and reporting
5. To know the requirements, process and stages for disclosure, including the responsibility, apology issues
6. To learn the ethical, professional and legal obligations to disclose and report across all sites of health care and the legal implications arising from disclosure (link to Professional competency-commitment to ethical practice)
7. To learn about policies and procedures related to disclosure
8. To know how to report an adverse event/close call
9. To understand event analysis

Skills

1. To recognize an adverse event/close call
2. To assess safety for patient and family and intervene as required
3. To reduce and manage risk of further harm
4. To disclose an adverse event to a patient (as appropriate) and family
5. To provide appropriate support for health care professional and team involved (link to Professional competency-commitment to physician health and sustainable practice)
6. To recognize patients in vulnerable situations re disclosure
7. To communicate honestly, empathically and clearly during disclosure
8. To document unexpected outcomes, adverse events and the disclosure discussions
9. To provide ongoing follow up as needed for patient and family, participate in event analysis as appropriate and apply lessons learned from event analysis

Attitudes/behaviours

1. To be responsible for ethical and professional behaviour in reporting adverse events and disclosure to patients and families (link to Professional competency-commitment to ethical practice)
2. Engage in reflection re adverse event (link to Scholar competency-ongoing learning)
3. Advocate for system change as warranted (link to Health Advocate competency- advocate for health and patient safety)

Content:

1. SickKids Disclosure PowerPoint presentations - attached (see below)
2. Examples of hospital policies - Provided by individual programs
3. Official Provincial Apology Acts and legislation must be obtained from
4. Statutory Publications
5. Case based presentations
6. CMPA Disclosure Booklet - attached (see below)
7. CPSI Root cause analysis-attached (see below)

Teaching methodologies:

Academic half day interactive sessions:

1.    Session 1-2 hours:

• Case presentation and slide deck on disclosure- attached

2.    Session 1-2 hours

• Role play disclosure using the case above or a local case; use residents and faculty (or Standardized Patients if available).
• Use required elements for disclosure to ensure all points are covered.
• Discuss the issues related to apology and use apology act from the appropriate province.-attached
• Discuss ethical and legal implications of disclosure.
  

3.    Session 1 hour:

• Review the reporting mechanisms available at local site, what happens to the reports and describe recent changes based on reports.

4.    Session 1 hour:

• Describe a root cause analysis- see attached from CPSI
• Use local example of analysis of recent event.

Other learning opportunities:

• Attend disclosure meeting (if possible).
• IHI Open School - Available at no cost but you must register with them

Evaluation:

The learner

• MCQ format
• Short Answer Questions
• Card Sessions
• OSCE

Program/session/module

• Feedback from learners
• Outcomes of tests on learners
• Performance outcome of learners

Supporting materials/videos etc:

1. Institute for Healthcare Communication - Disclosure Course

Domain 6 Attachments

CMPA Disclosure Booklet 2008.pdf
CPSI Root Cause Analysis Framework.pdf
Capital Health Disclosure_1august08_proof.pdf
Domain 6 Case
Domain 6 Case Facilitator Guide