Risk Management&

Disclosure

Kirsten Thomson, November 2012

My Portfolio

Patient Safety Learning System (PSLS)

Risk management Education affiliation agreements Insurance

PSLS

Add and deactivate users Provide training Provide final approval to all events

reported in system Trending and analysis Review for potential claims

Risk Management Critical incident and Section 51 quality

reviews Point person for legal affairs Contract risk/indemnification Maintain risk policies and procedures Consult on risk of other department P&P Risk evaluation of new projects/initiatives General risk advice

Insurance - HCPP

Our “insurer” and risk advisors Provide NH with liability, property,

directors & officers, and some crime coverage– Physicians covered by HCPP only for

administrative work We report serious adverse events They provide legal counsel

Reporting Events

PSLS– Can only be done on computers

connected to the NH network Department channels

– Department head, chief of staff, department manager

Directly to me

What kinds of events to report NH policy 2-1-3-030-P Patient Safety

Management System (PSLS)“NH employees and medical staff will report, document and

manage all client-related incidents and near misses on the PSLS incident reporting system.”

Events that caused harm (critical incidents – loss of life, limb or vital organ)

“An event is an incident/error/mistake or any happening that is not consistent with the routine operation of the facility/service or the routine care of a particular patient”

Events that you might report to CMPA

“Must Report” EventsSurgical events1. Surgery performed on the wrong body part2. Surgery performed on the wrong patient3. Wrong surgical procedure performed on a patient4. Unintended retention of a foreign object in a

patient after surgery or other procedure5. Intraoperative or immediately postoperative

death in an American Society of Anesthesiologists Class I patient

Product or device events

6. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the health care facility

7. Patient death or serious disability associated with the use or function of a device inpatient care, in which the device is used for functions other than as intended Patient Safety Event Management (PSLS) 2‐1‐3‐030‐P

8. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a health care facility

Patient protection events 9. Infant discharged to the wrong person10. Patient death or serious disability

associated with patient elopement/disappearance

11. Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a health care facility

Care management events12. Patient death or serious disability associated with a medication

error (wrong drug/ dose/patient/time/rate/preparation/route)13. Patient death or serious disability associated with a hemolytic

reaction due to administration of ABO/HLA incompatible blood or blood product

14. Maternal death or serious disability associated with labor or delivery in a low risk pregnancy while being cared for in a health care facility

15. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility

16. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates

17. Stage 3 or 4 pressure ulcers acquired after admission to a health care facility

18. Patient death or serious disability due to spinal manipulative therapy

Environmental events19. Patient death or serious disability associated with an electric

shock or electrical cardioversion while being cared for in a health care facility

20. Any incident in which a line designated for oxygen or gas to be delivered to a patient contains the wrong gas or is contaminated.

21. Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility.

22. Patient death or serious disability associated with a fall while being cared for in a health care facility.

23. Patient death or serious disability associated with the use of restrains or bedrails while being cared for in a health care facility.

Criminal Events24. Any instance of care ordered by or provided by

someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.

25. Abduction of a patient of any age.26. Sexual assault on a patient within or on the grounds of

the health care facility.27. Death or significant injury of a patient or staff member

resulting from a physical assault (e.g. battery) that occurs within or on the grounds of the health care facility.

What happens following an event?

Critical incidents undergo quality review– Reported to HCPP; legal counsel may be

assigned Non-critical incidents are tracked and

trended– PSLS no harm events

Disclosure NH Disclosure of Adverse Events policy (4-2-0-

030-P)“Any adverse event where there is harm, injury or complication

due to health care service delivery should be disclosed to the Client.”

“Northern Health physicians, managers, health care providers and administrators must work together to ensure that appropriate disclosure to clients or their representatives is a routine part of the response to an adverse event.”

“Disclosure of near misses is a matter of clinical and professional judgment. If it could assist the client in the future to know that a mistake was nearly made, it should be disclosed”

Disclosure Canadian Patient Safety Institute (CPSI) –

Canadian Disclosure Guidelines“Patients are entitled to information about themselves

and about their medical condition or illness, including the risks inherent in healthcare delivery.”

Current literature, national and international leading practices, and ethical, professional and legal considerations all support open and honest disclosure of patient safety incidents, as it is important for all concerned.”

Disclosure - CPSI“Healthcare providers have ethical obligations

to be open and honest when communicating with patients. Most professional codes of conduct specifically require disclosure. Patients have a right to relevant information about all aspects of their care and healthcare providers have a corresponding obligation to provide that information to patients without being asked and to answer their questions.”

Disclosure – Accreditation Canada

Includes a Required Organizational Practice for disclosure

“Organizations must implement a formal and transparent policy and process of disclosure to patients, which includes support mechanisms for patients, family and care of service providers.”

Disclosure - CMPA“An adverse event is one which results in unintended

harm to the patient and is related to the care and/or services provided to the patient rather than to the patient’s underlying medical condition”

“The CMPA has for many years encouraged member physicians to disclose to patients the occurrence and nature of adverse outcomes as soon as is reasonable to do so after their occurrence. This is an ethical, professional and legal obligation.”

References NH Policy 4-2-0-030-P Disclosure of Adverse

Events (Nov 2011) NH Policy 2-1-3-030-P Patient Safety

Management System (PSLS) (March 2011) CMPA Disclosing adverse events to patients:

strengthening the doctor-patient relationship (May 2008)

CPSI Canadian Disclosure Guidelines: Being Open with Patients and Families (2011)