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Saturday, July 24, 2010

Mastering Adverse Outcome

Approximately 10% of medical encounter resulted in adverse outcome. If this is applied to aviation industry, it means 50 plane will crash at Dublin airport on daily basis!
How do they maintain the high standard of care?
So, how did the aviation industry tackle the scenario? Pilot used to be employed from army, hence the smart uniform and discipline that they still right now - although there is no relationship anymore with defence forces. As we know in army, they rely very much on not questioning the order of the superior. However, the aviation industry challenged this type of culture by normalising respectful assertive communication across the profession. What this means is that co-pilot are free to communicate his worries to the captain assertively, and this has become the norm in the industry. This is very far from what we have been practiign in medicine.

To break the norm is always proven difficult. How can you say to your consultant that you think what he did was not appropriate? In the MPS workshop recently, the presenter adviced on a formula, the square root of n. That is apparently the formula to change the culture/habit of a place. Lets say there are 100 angry people in the workplace. Base on this theory, it only requires10 people to start making changes (ie to be nice), then others will follow suit. I tried to googled it, but could not find any further information on this (eg: study/origin etc).

Confronting an adverse effect from our intervention is a daunting experience. It does not necessarily mean that we are at fault, but it will certainly throw a lot of guilty feeling deep inside. Did I not do enough to prevent this from happening? Could I foresee this coming? Different people then will take different steps. Some will of course apologise but unfortunately some will blame others. We all have gone through the feeling when something like that happened to us, I am pretty sure of that. The culture of blame and shame should have long gone. That will hinder a proper investigation to be carried out. Once we know what was wrong, then we can proceed to explain it to the patient involved and perhaps prevent it from happening to other people. remember the story of how an intern mistakenly gave KCl instead of normal saline solution, and the heart stop beating? The outcome from this was that there should be no KCl next to saline to reduce this probability. KCl is not available to everybody except for certain few, and rigorous label checking at every point of treatment.

In the workshop that I attended, one thing that caught my attention was the discussion on how the doctor was coping when we are involved in adverse events. As usual, there was a video session with a doctor who has little clue on how to communicate properly. Of course our task was to learn on what not to do. But it was interesting to observe how we (who are supposed to observe professional integrity) quickly jump into accusation and our pre-made conculsion on how bad the doctor is. Are we that quick as well in passing comments in real life about our own colleague?

Throughout the workshop, the take home message was that patients who were involved in the adverse event should be informed of what was happening, and we as a doctor should feel sorry of what was happening to them (sympathy). This obviously has provoked a lengthy discussion. There was an argument that by saying sorry, we are admitting liability and that will not look good in the court of law. If we are worried about this, then the advice is to sympathise with the outcome (say: I am sorry that this is happening to you/saya bersimpati atas apa yang berlaku pada pakcik) instead of indicating that we are sorry that it was our mistakes that it happened. Document what we say properly so that the next person will know whether was it a sorry for mistake and just for sympathy. This is also the position of MPS and HSE - that the patients should understand fully on what is happening, and they should not be kept in the dark.

It is not the same as when we have car accident. Lawyers and our insurance company will ceratinly advice us not to admit that we are at fault. Apart from exchanging details, let them sorted out who are at fault over the accident. This defensive culture has creeped up into the medical community. many studies have shown that by being open and transparrent with the patient, the litigation rates are supprisingly on the way down (Kraman & Hamm 1999, Liebman 2005, Quinn 2008).

One thing I believe we should be practicing even on individual level is to help our fellow doctors/nurses in dealing with death of our pateints. One of the doctors in the course told a story of hers, how traumatic it was for her (as a junior doctor) to encouter death of a patient for the first time. One time there was a person who unfortunately involved in a fire. He got nearly 100% burn all over his body. He did not feel the pain as it was a 3rd degree burn, but everybody knew that he is not going to survive. He said at that time that he will be out in 2 months to work againn, and he was still lucid. 3 days later, he died. After the incident happen, all the nurses who were involve din dealing with the patient waere called up into a room and were de-briefed of what was hapepnign etc. The doctors? They were told that they were many cards waiting to be seen (in A&E). the very least we can do is to approach our fellow doctor and say to him, is there anything you want to tell me? Are you ok? How are you coping?

One technique that we learnt on how to deal with adverse events was to apply A.S.S.I.S.T technique.

A Acknowledge (that there has been a problem)
S Sorry (that this is happening)
S Story (in patients own word, what was happening?)
I Inquire (what answer the patients look for? Request permission to provide further info)
S Solution (request permission to propose some lan and to agrre on them)
T Travel (to have follow up)

It has been great to take some time off to attend these lectures. I wish I could attend the next in the series 'mastering professional interaction', but I don't think it will be avaialble in Malaysia or before i leave Ireland.



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