scholarly journals LO66: Strengthening team communication may decrease medico-legal risk for physicians in the emergency department

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S31-S32
Author(s):  
A. MacIntyre ◽  
Q. Yang ◽  
R. De Gorter ◽  
S. Lee ◽  
L. Calder
Keyword(s):  
Emergency Department ◽  
Patient Safety ◽  
Descriptive Analysis ◽  
Healthcare Providers ◽  
Team Communication ◽  
Legal Cases ◽  
Team Members ◽  
Legal Risk ◽  
For Profit ◽  
Enhance Patient Safety

Introduction: In a busy emergency department (ED), effective communication is integral to the provision of safe medical care. Physicians working in the ED interact with multiple team members including patients, allied healthcare professionals and other physicians, who all need to understand their verbal and written instructions. Our study's objective was to identify and describe communication problems occurring in the ED setting, and how these problems contributed to patient safety events and increased medico-legal risk for physicians. Methods: The Canadian Medical Protective Association (CMPA) is a not-for-profit, medico-legal organization which represented over 97,000 physicians at the time of this study. We conducted a retrospective descriptive analysis where we extracted five years (2013-2017) of CMPA data describing closed medico-legal cases occurring in the ED involving physicians (any specialty) who experienced complaints due to communication issues. We then applied an internal contributing factor framework to identify data themes. Data were summarized using descriptive statistics. Results: We identified 517 eligible cases involving 521 patients (some cases involved >1 patient). We found that 99.8% (520/521) of patients experienced some form of healthcare-related harm in the ED. Specifically, there was poor communication between: the physician and patient or patient's family (202/517, 39.1%); two or more physicians (79/517, 15.3%), and physicians and other healthcare providers (55/517, 10.6%). Inadequate documentation was observed in more than half of the cases (324/517, 62.7%) and poor team communication affected physicians’ decision making process (326/517, 63%) in areas such as deficient assessments, inadequate investigations, failure or delay to attend to the patient, and disposition decisions. Conclusion: Team communication issues are prevalent among physician medico-legal cases occurring in the ED. Efforts to strengthen communication skills may enhance patient safety and reduce medico-legal risk.

scholarly journals Malpractice Claimed Calls within the Swedish Healthcare Direct: A Descriptive – Comparative Case Study

2020 ◽  
Author(s):  
Annica Bjorkman ◽  
Maria Engström ◽  
Ulrika Winblad ◽  
Inger K Holmström
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Work Groups ◽  
Healthcare Providers ◽  
Total Sample ◽  
Comparative Case Study ◽  
Healthcare Organizations ◽  
Computerized Decision Support ◽  
Malpractice Claims ◽  
Enhance Patient Safety

Abstract Background: Medical errors are reported as a malpractice claim, and it is of uttermost importance to learn from the errors to enhance patient safety. The Swedish national telephone helpline SHD is staffed by registered nurses; its aim is to provide qualified healthcare advice for all residents of Sweden; it handles about 5 million calls annually. The aim of the present study was twofold: to describe all malpractice claims and healthcare providers’ reported measures regarding calls to Swedish Healthcare Direct (SHD) during the period January 2011-December 2018 and to compare these findings with results from a previous study covering the period 2003-2010.Methods: The study used a descriptive and comparative design. A total sample of all reported malpractice claims regarding calls to SHD (n=35) made during the period 2011-2018 was retrieved. Data were analysed and compared with all reported medical errors during the period 2003-2010 (n=33). Results: Telephone nurses’ failure to follow the computerized decision support system (CDSS) (n=18) was identified as the main reason for error during the period 2011-2018, while failure to listen to the caller (n=12) was the main reason during the period 2003-2010. Staff education (n=21) and listening to one’s own calls (n=16) were the most common measures taken within the organization during the period 2011-2018, compared to discussion in work groups (n=13) during the period 2003-2010.Conclusion: The proportion of malpractice claims in relation to all patient contacts to SHD is still very low; it seems that only the most severe patient injuries are reported. The fact that telephone nurses’ failure to follow the CDSS is the most common reason for error is notable, as SHD and healthcare organizations stress the importance of using the CDSS to enhance patient safety. The healthcare organizations seem to have adopted a more systematic approach to handling malpractice claims regarding calls, e.g., allowing telephone nurses to listen to their own calls instead of having discussions in work groups in response to events. This enables nurses to understand the latent factors contributing to error and provides a learning opportunity.

The Timely Open Communication for Patient Safety Project

2013 ◽  
Vol 3 (1) ◽  
Author(s):  
Margo Lynn Paterson ◽  
Jennifer Medves ◽  
Nancy Dalgarno ◽  
Anne O'Riordan ◽  
Robyn Grigg
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Educational Interventions ◽  
Open Communication ◽  
Interprofessional Communication ◽  
Team Members ◽  
Face To Face ◽  
Enhance Patient Safety ◽  
Educational Modules ◽  
Research Period

Background: Concern is growing over increased numbers of adverse events experienced by patients when admitted to acute care hospitals in Canada due to breakdowns in communication. The purpose of the Timely Open Communication for Patient Safety (TOC) project was to create a culture of patient safety through enhanced interprofessional communication by developing resources for caregivers and patients. Methods and Findings: The research was framed by a mixed methods design that included pre- and post-surveys and focus groups, online educational modules, face-to-face activities, and the development of patient orientation materials. Three clinical sites participated in the study. The findings indicate that supporting healthcare teams to identify strengths, challenges, and future directions of communicating, clarifying roles, functioning, and collaborating, coupled with educational interventions that raise awareness of patient safety,may enhance patient safety. The study was limited by the absence of data regarding the incidence of adverse events during the research period. Conclusion: The data showed improvement in team members' perceptions of interprofessional collaborative practice within the participating Collaborative Learning Units (CLUs). If the CLU model of care is adopted within the healthcare system, the safety of patients/clients may improve.

scholarly journals Malpractice claimed calls within the Swedish Healthcare Direct: a descriptive – comparative case study

BMC Nursing ◽  
2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Annica Björkman ◽  
Maria Engström ◽  
Ulrika Winblad ◽  
Inger K. Holmström
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Work Groups ◽  
Healthcare Providers ◽  
Total Sample ◽  
Comparative Case Study ◽  
Healthcare Organizations ◽  
Computerized Decision Support ◽  
Malpractice Claims ◽  
Enhance Patient Safety

Abstract Background Medical errors are reported as a malpractice claim, and it is of uttermost importance to learn from the errors to enhance patient safety. The Swedish national telephone helpline SHD is staffed by registered nurses; its aim is to provide qualified healthcare advice for all residents of Sweden; it handles normally about 5 million calls annually. The ongoing Covid-19 pandemic have increased call volume with approximate 30%. The aim of the present study was twofold: to describe all malpractice claims and healthcare providers’ reported measures regarding calls to Swedish Healthcare Direct (SHD) during the period January 2011–December 2018 and to compare these findings with results from a previous study covering the period January 2003–December 2010. Methods The study used a descriptive, retrospective and comparative design. A total sample of all reported malpractice claims regarding calls to SHD (n = 35) made during the period 2011–2018 was retrieved. Data were analysed and compared with all reported medical errors during the period 2003–2010 (n = 33). Results Telephone nurses’ failure to follow the computerized decision support system (CDSS) (n = 18) was identified as the main reason for error during the period 2011–2018, while failure to listen to the caller (n = 12) was the main reason during the period 2003–2010. Staff education (n = 21) and listening to one’s own calls (n = 16) were the most common measures taken within the organization during the period 2011–2018, compared to discussion in work groups (n = 13) during the period 2003–2010. Conclusion The proportion of malpractice claims in relation to all patient contacts to SHD is still very low; it seems that only the most severe patient injuries are reported. The fact that telephone nurses’ failure to follow the CDSS is the most common reason for error is notable, as SHD and healthcare organizations stress the importance of using the CDSS to enhance patient safety. The healthcare organizations seem to have adopted a more systematic approach to handling malpractice claims regarding calls, e.g., allowing telephone nurses to listen to their own calls instead of having discussions in work groups in response to events. This enables nurses to understand the latent factors contributing to error and provides a learning opportunity.

Simulation in Medicine: Addressing Patient Safety and Improving the Interface Between Healthcare Providers and Medical Technology

2006 ◽  
Vol 40 (5) ◽  
pp. 399-404 ◽  
Author(s):  
Elizabeth A. Hunt ◽  
Kristen L. Nelson ◽  
Nicole A. Shilkofski
Keyword(s):  
Patient Safety ◽  
Medical Technology ◽  
Healthcare Providers ◽  
Hospital Setting ◽  
Medical Simulation ◽  
Human Factors Engineering ◽  
Safe Environment ◽  
Enhance Patient Safety ◽  
History Of ◽  
And Performance

Abstract Medicine, as an industry in which human lives depend on the skill and performance of operators, must create and maintain a culture of safety, in addition to promoting the design of systems to mitigate errors. The use of medical simulation as a mechanism for training healthcare professionals in a safe environment is expanding rapidly. An important component of systems that ensure the safety of patients in the hospital setting is the interface between humans and technology in the hospital. The objective of this paper is to review: (1) the definition and a brief history of medical simulation, (2) examples of how current medical simulation centers are using simulation to address patient safety, and (3) examples of how simulation can be used to enhance patient safety through improvement of the interface between healthcare practitioners and medical technology. Medical simulation and human factors engineering can be used to examine and enhance the interface between health-care practitioners and medical technology, with the potential to make a significant contribution to patient safety.

The Role of Interpersonal Relations in Healthcare Team Communication and Patient Safety

2017 ◽  
Vol 49 (2) ◽  
pp. 75-93 ◽  
Author(s):  
Charlotte Tsz-Sum Lee ◽  
Diane Marie Doran
Keyword(s):  
Patient Safety ◽  
Team Performance ◽  
Interpersonal Relations ◽  
Improve Patient Safety ◽  
Healthcare Providers ◽  
Theoretical Framework ◽  
Healthcare Team ◽  
Team Communication ◽  
Interpersonal Processes ◽  
Communicative Behavior

Patient safety is compromised by medical errors and adverse events related to miscommunications among healthcare providers. Communication among healthcare providers is affected by human factors, such as interpersonal relations. Yet, discussions of interpersonal relations and communication are lacking in healthcare team literature. This paper proposes a theoretical framework that explains how interpersonal relations among healthcare team members affect communication and team performance, such as patient safety. We synthesized studies from health and social science disciplines to construct a theoretical framework that explicates the links among these constructs. From our synthesis, we identified two relevant theories: framework on interpersonal processes based on social relation model and the theory of relational coordination. The former involves three steps: perception, evaluation, and feedback; and the latter captures relational communicative behavior. We propose that manifestations of provider relations are embedded in the third step of the framework on interpersonal processes: feedback. Thus, varying team-member relationships lead to varying collaborative behavior, which affects patient-safety outcomes via a change in team communication. The proposed framework offers new perspectives for understanding how workplace relations affect healthcare team performance. The framework can be used by nurses, administrators, and educators to improve patient safety, team communication, or to resolve conflicts.

Surgical Fires and Burns: A 5-Year Analysis of Medico-legal Cases

2019 ◽  
Vol 40 (6) ◽  
pp. 886-892
Author(s):  
Lisa A Calder ◽  
Diane L Héroux ◽  
Catherine A Bernard ◽  
Richard Liu ◽  
Heather K Neilson ◽  
...  
Keyword(s):  
Situational Awareness ◽  
Descriptive Analysis ◽  
Supplemental Oxygen ◽  
Team Communication ◽  
Coding System ◽  
Surgical Team ◽  
Contributing Factors ◽  
Legal Cases ◽  
Surgical Safety ◽  
Safety Interventions

Abstract Surgical fires and unintended intraoperative burns cause serious patient harm, yet surveillance data are lacking in Canada. Medico-legal data provide unique descriptions of these events which can inform burn prevention strategies. We extracted 5 years of data on closed (2012–2016) medico-legal cases involving surgical fires and burns from the database of our organization which, in 2016, provided medico-legal support to >93,000 Canadian physicians. We performed a retrospective descriptive analysis of contributing factors using an in-house coding system and case reviews. We identified 53 eligible burn cases: 26 from thermal sources (49.1%), 16 from fires (30.2%), 5 from chemical sources (9.4%), and 6 from undetermined sources (11.3%). Common burn sources were electrosurgical equipment, lasers, lighting, and improper temperatures (causing thermal burns), cautery or lasers combined with supplemental oxygen and/or a flammable fuel source (causing fire), and improperly applied solutions including antiseptics (causing chemical burns). Nontechnical factors also contributed to patient outcomes, such as nonadherence to protocols (15 cases, 28.3%), failures in surgical team communication (3 cases, 5.7%), and lost situational awareness leading to delays in recognizing and treating burns (7 cases, 13.2%). This retrospective study highlights a need for improved surgical safety interventions to address surgical fires and burns. These interventions could include: effectively implemented surgical safety protocols, surgical team communication strategies, and raising awareness about preventing, diagnosing, and managing surgical burns.

scholarly journals P004: Simulation for emergency department quality improvement

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S58-S58
Author(s):  
J. B. Baylis ◽  
J. Slinn ◽  
K. Clark
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Simulation Program ◽  
Quality Improvement Initiative ◽  
Team Communication ◽  
In Situ Simulation ◽  
Team Members ◽  
Action Item ◽  
Simulation Session

Introduction: There have been an increasing number of studies published since 2011 investigating the benefits of in situ simulation as a quality improvement (QI) modality. We instituted an emergency department (ED) in situ simulation program at Kelowna General Hospital in 2015 with the aims of improving inter-professional collaboration, improving team communication, developing resident resuscitation leadership skills, educating ED professionals on resuscitation medical expertise, and identifying QI action items from each simulation session. Methods: We applied the SMART framework. Our specific, measureable, and attainable goal was to select two QI action items discovered from each simulation session. Realistic and timely follow-up on each action item was conducted by the nurse educator group who reported back to the local ED network, pharmacy, or manager depending on the action item. This ensured sustainability of our model. Results: A total of 65 individuals participated in 2015 at program inception. This increased to 213 individuals in 2017 with an average of 24 participants/session. Attendants included nurses (31%), ED physicians (20%), ED residents (18%), paramedics (10%), and medical students, respiratory therapists, pharmacists, and others (21%). Our QI action items were grouped as (1) team/communication, (2) equipment/resources, and (3) knowledge/tasks. Examples of each category were: (1) Inability to hear paramedic bedside reports resulting in reinforcement of one paramedic speaking while the team remains quiet, (2) Difficulty in looking up medication information in the resuscitation bay resulting in installation of an additional computer in the resuscitation bay, and (3) Uncertainty of local process for initiating extra corporeal membrane oxygenation (ECMO) in the ED resulting in review of team placement, patient transfer, and initiation of ECMO lines in the ED. Inter-professional team members have reported through electronic feedback on the value of these sessions, including improved inter agency cooperation and understanding. Conclusion: This quality improvement initiative used in situ simulation as a QI tool. We were able to identify latent safety threats, test new patient care protocols, find equipment issues, and foster teamwork in a sustainable way to improve the quality of care in our ED. We hope that this serves as encouragement to others who are initiating a similar program. Our main suggestions after reflection include: (1) Engage a multidisciplinary team in the development of an in situ simulation program, (2) Start with aims and objectives, (3) Foster attendance and buy in by making it convenient for people to attend, (4) Celebrate your successes through interdepartmental communication, and (5) Recruit individuals with expertise in simulation based education.

10. Designing an online curriculum supporting risk management and patient safety

2007 ◽  
Vol 30 (4) ◽  
pp. 33
Author(s):  
T. Gondocz ◽  
G. Wallace
Keyword(s):  
Risk Management ◽  
Medical Education ◽  
Patient Safety ◽  
Online Learning ◽  
Online Courses ◽  
Learning System ◽  
Online Curriculum ◽  
For Profit ◽  
Not For Profit ◽  
Managing Risk

The Canadian Medical Protective Association (CMPA) is a not for profit mutual defence organization with a mandate to provide medico-legal assistance to physician members and to educate health professionals on managing risk and enhancing patient safety. To expand the outreach to its 72,000 member physicians, the CMPA built an online learning curriculum of risk management and patient safety materials in 2006. These activities are mapped to the real needs of members ensuring the activities are relevant. Eight major categories were developed containing both online courses and articles. Each course and article is mapped to the RCPSC's CanMEDS roles and the CFPC's Four Principles. This poster shares the CMPA’s experience in designing an online patient safety curriculum within the context of medico-legal risk management and provides an inventory of materials linked to the CanMEDS roles. Our formula for creation of an online curriculum included basing the educational content on real needs of member physicians; using case studies to teach concepts; and, monitoring and evaluating process and outcomes. The objectives are to explain the benefits of curricular approach for course planning across the continuum in medical education; outline the utility of the CanMEDS roles in organizing the risk management and patient safety medical education curriculum; describe the progress of CMPA's online learning system; and, outline the potential for moving the curriculum of online learning materials and resources into medical schools.

Sign in / Sign up

Export Citation Format

Share Document