Talking with Patients and Families about Medical Error: A Guide for Education and Practice

Index

167 Index ability of organization to intervene, developing, 123, 126–29 accountability: apology and, 71–72; ascribing for bad outcomes, 13–14; avoidance of, 32; communication about, 119–20; as core relational value, 67; definition of, 67; following up and, 81; organizational, establishing , 123, 125–26 Accreditation Council on Graduate Medical Education, 29 action, turning ability into, 123, 129–30 actors in enactments, role of, 92, 93–94, 102 adverse events: communication about, 14; definitions of, 12–13, 13; goal of reduction to zero, 29–30; measurement of, 16; moral and emotional salience of, 62–63; as part of health care, xiv; positive outcomes after, 99–100 aesthetics of imperfection, 118, 137 Agency for Healthcare Research and Quality (AHRQ): adverse event definition of, 12; first national report on, 25; hospital survey on patient safety culture, 27, 28; IOM report and, 22; medical error definition of, 10–11; patient safety indicators, 26 agendas, setting, 84 AHRQ. See Agency for Healthcare Research and Quality American Association for the Advancement of Science, 17 American College of Physicians, 36 American College of Surgeons, 36 American Medical Association: Code of Ethics, 36, 112; conference on patient safety and, 17 American Nurses Association, 36 American Society for Healthcare Risk Management (ASHRM): adverse event definition of, 12; on disclosure, 15; IOM report and, 24 apology: accountability and, 71–72; conveying, 86–87; types of, 70–72 apology laws, 50–51 ASHRM. See American Society for Healthcare Risk Management ask-tell-ask method, 70, 77, 84–85 attention to medical needs of patients, ensuring, 75 attitude surveys, 123–24 autonomy, principle of, 34 aviation industry, response to errors within, 20–21 awareness of importance of disclosure, promotion of, 122–25, 123 bad apple mentality, xiii, 17–18 Banja, John, 13, 41 Bataldan, Paul, 16 Berlinger, Nancy, 35 Berwick, Don, 16, 17, 66 Page numbers in italics refer to figures and tables. 168 INDEX blame: accepting, 99; act of assigning, 97–98, 126 Boothman, Richard, 46, 47 Brigham and Women’s Hospital, 53, 54–55 caring: apology as expression of, 70–71; conveying, 86–87; expressing, 82 casuistry, 103–4 Catholic Health Initiatives, 54 Chan, D. K., 39 change, importance of, vii–viii, 73 Children’s Hospital Boston, 58 clinical disclosures, 52 clinicians: apologies from organizations to, 120; ask-tell-ask method and, 77; as coaches, 60; meeting needs of, 78–79, 90; primary conversations and, 61–62, 79; self-efficacy of, 101–2; support for, 127, 133–34; tendency to blame and, 97–98. See also physicians Clinton, Hillary, xiv, 22, 47, 49 coaching model of disclosure, 58–63 communication with patients: about adverse events, 14; acquisition of “skills” for, xvii–xviii; approaches to demonstrated in workshops, 96–101; challenges and complexity of, 57–58; as collaborative, 69–70, 84–85, 134–35; as in developmental infancy, 104–5; discrepancy between what is known and what is practiced in, viii; documentation of, 90–91; education and training for, 42, 136; elements of, 74–75; facts, stating, 80, 85–86, 96–97; following up after initial conversations, 81, 89, 127; illustration of breakdown in, 1–3; lawsuits and, xiv; needs and desires for, 31–33; timing of and settings for, 81, 106 compassion: conveying, 82, 83, 87; definition of, 68 compensation: acknowledging issues of, 88–89; offers of, 55, 134–35 conflict between ethical principles, 35, 72–73 “connect the dots” disclosures, 39 consequentialism, principle of, 34 Consumers Advancing Patient Safety, vii context, effects of on disclosure conversations, 101 continuity: as core relational value, 67; definition of, 67; following up and, 81; primary caregivers and, 80 conversations. See communication with patients COPIC Insurance Company, 53, 55, 56, 134 Crigger, Nancy, 11 culture: of blame, 98; of silence, xiii, 18, 40–42 culture of health care institutions: as dysfunctional, viii; importance of change in, 56, 129–30, 137. See also culture, of silence curriculum for disclosure coaches: core relational values and, 66–67; design of, 64–65; overview of, 62–63 “dashboards,” 131 debriefing conversations, 90 “deferring” disclosures, 40 delays in diagnosis, 106 disclosure malfunction, viii disclosure of error: barriers to, 121–22, 130; benefits of, 37–38; categories of, 52; coaching model of, 58–63; effect of on clinicians, 43–44; effect of on malpractice litigation, 44–50; ethical norms regarding, 33–36; as exception rather than norm, 38–43; institutional support for, 59–62; integration of into institutional safety and quality programs , 131–33; levels of, xvi; programs and policies regarding, 51–56; safe practice guideline on, 59...