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The aftermath of a medical error can be an endless tangle of bad feelings, or it can yield valuable lessons for hospital teams.
Adverse events need to be approached as learning opportunities, and a short checklist can start the process, according to Dr. Kimberly D. Manning of Emory University, Atlanta.
She and her colleague Dr. Neil H. Winawer have developed a standardized list of questions for assessing one’s role in adverse events and medical errors. The checklist gets at what went right, what could have been done better, and how to approach similar situations differently in the future.
Taking a standardized approach to medical errors is aimed at bringing more personal accountability into the analysis of adverse events, said Dr. Winawer, director of the hospital medicine unit at Grady Memorial Hospital, Atlanta. "Not every mistake has its origins inside of a system, and there needs to a balance of a no-fault systems culture and accountability," he said.
Dr. Manning added that not every adverse event requires a systems change. "Sometimes it just involves ... sitting down with your team, or alone, and working through exactly what happened to get the lessons and move forward," she said.
The checklist includes a series of must-ask questions, starting with a description of the adverse outcome or pivotal event. Other questions elicit explanations of what the physician did (or did not do) that was not ideal for the patient. And the checklist asks physicians to think about what they did that was good for the patient.
"What we found from having these discussions with our house staff is that the patients we tend to feel the most terrible about are usually the people that we’ve invested a lot into," said Dr. Manning, who is the director of Emory’s transitional year residency program.
It’s important to think about all the high-quality care that was provided, before and after something went wrong, rather than just dwelling on the adverse event, she said.
The checklist also focuses on the future, asking physicians what they could have done differently, what they have learned from the situation, and what safeguards could be implemented to avoid a similar outcome going forward.
The goal is to provide closure, but even more importantly, to honor the patient, Dr. Manning and Dr. Winawer explained.
To help physicians deal with the complex emotions surrounding an adverse event, the checklist includes some follow-up questions. The idea, Dr. Manning said, is to avoid the depression and burnout that can result unless perceived errors in care are discussed and dealt with.
The checklist can be used by individuals or with colleagues as a group. But it’s important to keep in mind that different members of the care team have different levels of responsibility and may have different views about the same event. Sometimes, the intern on the team did everything that he or she could do, Dr. Manning said, but the more senior physician could have done more to help the patient.
Because many adverse events are discovered by colleagues, the checklist also offers an objective way to discuss the problem and minimize some of the awkwardness.
Dr. Manning and Dr. Winawer spoke at the annual meeting of the Society of Hospital Medicine.
Checklist for Processing Errors and Adverse Events
Must-Ask Questions
• What was the adverse outcome or medical error?
• What did I do that was good for this patient?
• What did I do or not do that was not ideal?
• How high are the stakes?
• What could I have done differently?
• What did I learn?
• What can I do to avoid this happening again?
Follow-Up Questions
• How do I feel about what happened?
• What bothers me the most about this situation?
• What advice would you give to someone who was in this situation?
• How can I honor my patient now?
• What can I do to be of further support to my team members?
When my hospital embarked on a zero-defect campaign, I (like many of my colleagues) thought it was a great idea. It would help reduce morbidity and mortality and increase patient and family satisfaction, not to mention provider morale. However, many of us also had some trepidation about what the campaign would mean.
We physicians all want to provide the best care for our patients with a minimum of errors. However, when errors occur, they can be tough – especially if we were part of the error. We feel that we have failed our patients, and perhaps even ourselves.
We may experience guilt, which can be compounded by fear – fear of future adverse outcomes, fear of punitive actions from superiors, and even fear of malpractice or board actions for our mistakes, if they are significant. The blame game can cause extreme tension for the treatment team and be potentially toxic to a collegial and collaborative work environment.
Many of us will try to analyze what led to the defect. Having a checklist, as Dr. Manning and Dr. Winawer suggest, will help us to do that critical analysis in a more organized way. Some physicians may have frank conversations with the affected patients and apologize for the mistakes. Others may become more detail oriented and may be even more critical of themselves. Some may even practice defensive medicine to ensure that they do not repeat the same mistakes, even though the future clinical scenarios may be very different.
Fortunately, despite all the anxiety and doubts that such defects elicit, having supportive colleagues and a constructive work environment often help us deal with errors in a collegial manner, as well as in partnership with patients. The most important thing to appreciate is that the goal of zero defects is a process that involves commitment and ongoing, open, and honest dialogue – not only between us providers and our administration, but also among us and the patients and their families.
Anthony T. Ng, M.D., is a psychiatrist and chief medical officer at Acadia Hospital in Bangor, Maine.
When my hospital embarked on a zero-defect campaign, I (like many of my colleagues) thought it was a great idea. It would help reduce morbidity and mortality and increase patient and family satisfaction, not to mention provider morale. However, many of us also had some trepidation about what the campaign would mean.
We physicians all want to provide the best care for our patients with a minimum of errors. However, when errors occur, they can be tough – especially if we were part of the error. We feel that we have failed our patients, and perhaps even ourselves.
We may experience guilt, which can be compounded by fear – fear of future adverse outcomes, fear of punitive actions from superiors, and even fear of malpractice or board actions for our mistakes, if they are significant. The blame game can cause extreme tension for the treatment team and be potentially toxic to a collegial and collaborative work environment.
Many of us will try to analyze what led to the defect. Having a checklist, as Dr. Manning and Dr. Winawer suggest, will help us to do that critical analysis in a more organized way. Some physicians may have frank conversations with the affected patients and apologize for the mistakes. Others may become more detail oriented and may be even more critical of themselves. Some may even practice defensive medicine to ensure that they do not repeat the same mistakes, even though the future clinical scenarios may be very different.
Fortunately, despite all the anxiety and doubts that such defects elicit, having supportive colleagues and a constructive work environment often help us deal with errors in a collegial manner, as well as in partnership with patients. The most important thing to appreciate is that the goal of zero defects is a process that involves commitment and ongoing, open, and honest dialogue – not only between us providers and our administration, but also among us and the patients and their families.
Anthony T. Ng, M.D., is a psychiatrist and chief medical officer at Acadia Hospital in Bangor, Maine.
When my hospital embarked on a zero-defect campaign, I (like many of my colleagues) thought it was a great idea. It would help reduce morbidity and mortality and increase patient and family satisfaction, not to mention provider morale. However, many of us also had some trepidation about what the campaign would mean.
We physicians all want to provide the best care for our patients with a minimum of errors. However, when errors occur, they can be tough – especially if we were part of the error. We feel that we have failed our patients, and perhaps even ourselves.
We may experience guilt, which can be compounded by fear – fear of future adverse outcomes, fear of punitive actions from superiors, and even fear of malpractice or board actions for our mistakes, if they are significant. The blame game can cause extreme tension for the treatment team and be potentially toxic to a collegial and collaborative work environment.
Many of us will try to analyze what led to the defect. Having a checklist, as Dr. Manning and Dr. Winawer suggest, will help us to do that critical analysis in a more organized way. Some physicians may have frank conversations with the affected patients and apologize for the mistakes. Others may become more detail oriented and may be even more critical of themselves. Some may even practice defensive medicine to ensure that they do not repeat the same mistakes, even though the future clinical scenarios may be very different.
Fortunately, despite all the anxiety and doubts that such defects elicit, having supportive colleagues and a constructive work environment often help us deal with errors in a collegial manner, as well as in partnership with patients. The most important thing to appreciate is that the goal of zero defects is a process that involves commitment and ongoing, open, and honest dialogue – not only between us providers and our administration, but also among us and the patients and their families.
Anthony T. Ng, M.D., is a psychiatrist and chief medical officer at Acadia Hospital in Bangor, Maine.
The aftermath of a medical error can be an endless tangle of bad feelings, or it can yield valuable lessons for hospital teams.
Adverse events need to be approached as learning opportunities, and a short checklist can start the process, according to Dr. Kimberly D. Manning of Emory University, Atlanta.
She and her colleague Dr. Neil H. Winawer have developed a standardized list of questions for assessing one’s role in adverse events and medical errors. The checklist gets at what went right, what could have been done better, and how to approach similar situations differently in the future.
Taking a standardized approach to medical errors is aimed at bringing more personal accountability into the analysis of adverse events, said Dr. Winawer, director of the hospital medicine unit at Grady Memorial Hospital, Atlanta. "Not every mistake has its origins inside of a system, and there needs to a balance of a no-fault systems culture and accountability," he said.
Dr. Manning added that not every adverse event requires a systems change. "Sometimes it just involves ... sitting down with your team, or alone, and working through exactly what happened to get the lessons and move forward," she said.
The checklist includes a series of must-ask questions, starting with a description of the adverse outcome or pivotal event. Other questions elicit explanations of what the physician did (or did not do) that was not ideal for the patient. And the checklist asks physicians to think about what they did that was good for the patient.
"What we found from having these discussions with our house staff is that the patients we tend to feel the most terrible about are usually the people that we’ve invested a lot into," said Dr. Manning, who is the director of Emory’s transitional year residency program.
It’s important to think about all the high-quality care that was provided, before and after something went wrong, rather than just dwelling on the adverse event, she said.
The checklist also focuses on the future, asking physicians what they could have done differently, what they have learned from the situation, and what safeguards could be implemented to avoid a similar outcome going forward.
The goal is to provide closure, but even more importantly, to honor the patient, Dr. Manning and Dr. Winawer explained.
To help physicians deal with the complex emotions surrounding an adverse event, the checklist includes some follow-up questions. The idea, Dr. Manning said, is to avoid the depression and burnout that can result unless perceived errors in care are discussed and dealt with.
The checklist can be used by individuals or with colleagues as a group. But it’s important to keep in mind that different members of the care team have different levels of responsibility and may have different views about the same event. Sometimes, the intern on the team did everything that he or she could do, Dr. Manning said, but the more senior physician could have done more to help the patient.
Because many adverse events are discovered by colleagues, the checklist also offers an objective way to discuss the problem and minimize some of the awkwardness.
Dr. Manning and Dr. Winawer spoke at the annual meeting of the Society of Hospital Medicine.
Checklist for Processing Errors and Adverse Events
Must-Ask Questions
• What was the adverse outcome or medical error?
• What did I do that was good for this patient?
• What did I do or not do that was not ideal?
• How high are the stakes?
• What could I have done differently?
• What did I learn?
• What can I do to avoid this happening again?
Follow-Up Questions
• How do I feel about what happened?
• What bothers me the most about this situation?
• What advice would you give to someone who was in this situation?
• How can I honor my patient now?
• What can I do to be of further support to my team members?
The aftermath of a medical error can be an endless tangle of bad feelings, or it can yield valuable lessons for hospital teams.
Adverse events need to be approached as learning opportunities, and a short checklist can start the process, according to Dr. Kimberly D. Manning of Emory University, Atlanta.
She and her colleague Dr. Neil H. Winawer have developed a standardized list of questions for assessing one’s role in adverse events and medical errors. The checklist gets at what went right, what could have been done better, and how to approach similar situations differently in the future.
Taking a standardized approach to medical errors is aimed at bringing more personal accountability into the analysis of adverse events, said Dr. Winawer, director of the hospital medicine unit at Grady Memorial Hospital, Atlanta. "Not every mistake has its origins inside of a system, and there needs to a balance of a no-fault systems culture and accountability," he said.
Dr. Manning added that not every adverse event requires a systems change. "Sometimes it just involves ... sitting down with your team, or alone, and working through exactly what happened to get the lessons and move forward," she said.
The checklist includes a series of must-ask questions, starting with a description of the adverse outcome or pivotal event. Other questions elicit explanations of what the physician did (or did not do) that was not ideal for the patient. And the checklist asks physicians to think about what they did that was good for the patient.
"What we found from having these discussions with our house staff is that the patients we tend to feel the most terrible about are usually the people that we’ve invested a lot into," said Dr. Manning, who is the director of Emory’s transitional year residency program.
It’s important to think about all the high-quality care that was provided, before and after something went wrong, rather than just dwelling on the adverse event, she said.
The checklist also focuses on the future, asking physicians what they could have done differently, what they have learned from the situation, and what safeguards could be implemented to avoid a similar outcome going forward.
The goal is to provide closure, but even more importantly, to honor the patient, Dr. Manning and Dr. Winawer explained.
To help physicians deal with the complex emotions surrounding an adverse event, the checklist includes some follow-up questions. The idea, Dr. Manning said, is to avoid the depression and burnout that can result unless perceived errors in care are discussed and dealt with.
The checklist can be used by individuals or with colleagues as a group. But it’s important to keep in mind that different members of the care team have different levels of responsibility and may have different views about the same event. Sometimes, the intern on the team did everything that he or she could do, Dr. Manning said, but the more senior physician could have done more to help the patient.
Because many adverse events are discovered by colleagues, the checklist also offers an objective way to discuss the problem and minimize some of the awkwardness.
Dr. Manning and Dr. Winawer spoke at the annual meeting of the Society of Hospital Medicine.
Checklist for Processing Errors and Adverse Events
Must-Ask Questions
• What was the adverse outcome or medical error?
• What did I do that was good for this patient?
• What did I do or not do that was not ideal?
• How high are the stakes?
• What could I have done differently?
• What did I learn?
• What can I do to avoid this happening again?
Follow-Up Questions
• How do I feel about what happened?
• What bothers me the most about this situation?
• What advice would you give to someone who was in this situation?
• How can I honor my patient now?
• What can I do to be of further support to my team members?