In the past decade, research has shown that there is a growing concern about the number of adverse events in our health care system. The 2004 Canadian Adverse Events Study identified adverse events arising from the delivery of health care services as a significant problem in Canadian hospitals (Canadian Patient Safety Institute, 2008). The overall incidence was 7.5% of adverse events in that study, suggesting that of the 2.5 million hospital admissions annually, about 185,000 of those were associated with an adverse event and close to 70,000 of those were potentially preventable. Interestingly, it was noted that most of these took place in teaching hospitals. The study also indicated that the majority of patients who experienced an adverse event recovered without permanent disability. However, a significant number were also noted to have an increased length of hospital stay, as well as a temporary disability after discharge home. Despite the common goals and the best efforts of the health care team, outcomes may differ from what is desired or anticipated (Swiggum & Wallace, 2009).
Errors and adverse events occur more frequently in intensive care units (ICU) than in any other setting (Boyle, O'Connell, Platt, & Albert, 2006). The complexity of illness and trauma exponentially increases the risk of error and subsequent adverse events. In fact, errors and adverse events occur more often in ICUs, as patients frequently suffer from severe, multiple-system illnesses that require numerous interventions involving decision-making and planning from a number of health care providers. In general, patients with co-morbidities require more testing, monitoring and treatment, therefore increasing the risk of overlooking a critical physical finding, an important laboratory test, or a radiographic abnormality. Consequently, the patient has a greater risk of suffering from treatment- or procedure-related complications (Boyle et al., 2006).
All too frequently, the response to an adverse event focuses on identifying and blaming health care providers, with subsequent recommendations for greater vigilance, more training and, in some instances, professional sanctions for the individuals involved. Despite this approach, many adverse events continue to occur, while system failures are often overlooked when the blame is placed on individual providers (Swiggum & Wallace, 2009).
Over the past decade, the Canadian health care institutions have continued to make progress in the reporting of adverse events and disclosing these events to patients. In so doing, we continue to foster a more supportive environment where we can learn from these events and help prevent their recurrence.
In this article the authors share our learning experiences, as nurses and students, while working in critical care settings when disclosure guidelines were needed to communicate a harmful incident. A case study is used to illustrate the benefits of having a policy and a systematic framework in place to support a critical care environment in disclosing errors and adverse events to affected patients and their families.
Definitions
The terms "adverse event" and "sentinel event" are often used interchangeably in the literature. To be clear on the definitions, an adverse event is defined by the Canadian Patient Safety Institute (2008) as "an event that 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" (p. 8). A sentinel event, which is also considered an adverse event, is defined as "an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof. Such events are called 'sentinel' because they signal the need for immediate investigation and response from all levels of the health care team" (Daly, 2006, p. 28).
Consensus on full disclosure
Full disclosure is supported across North America by major health care organizations, such as the Joint Commission for Accreditation of Healthcare Organizations (2006), which requires licensed practitioners to inform patients and families whenever outcomes of care have differed from what was initially anticipated. In addition, the Canadian Council on Health Services Accreditation (CCHSA) requires health care organizations to implement a formal and transparent policy, as well as a process of disclosing adverse events to patients (CCHSA, 2007). This policy includes support mechanisms for patients and families, as well as for the service providers. Moreover, the Canadian Patient Safety Institute (CPSI) encourages and supports the development and implementation of policies, practices and training methods in relation to full disclosure (Boyle et al., 2006).
Nationally, the Canadian Nurses Association (CNA) code of ethics specifically mentions the topic of full disclosure. It states that "Nurses must admit mistakes and take all the necessary actions to prevent or minimize harm arising from an adverse event, [...] they work to ensure that health information is given to individuals, families [...] in an open, accurate and transparent manner" (CNA, 2008, p. 41). Furthermore, the CNA (2008) code of ethics outlines seven primary values that include "providing safe, compassionate, competent and ethical care," "promoting justice" and "being accountable" (p. 3). These primary values further emphasize the importance of full disclosure of adverse events in providing ethical nursing care to patients and families.
In addition to federal mandates, there is a trend emerging where provincial governments have also created legislation to guide practice regarding full disclosure. In 2006, British Columbia adopted the Apology Law, which aimed at dissolving the associations between disclosure and malpractice suits in order to sustain the movement toward a blame-free environment in health care settings (Levinson & Gallagher, 2007). This law stipulates that saying "I'm sorry" is not considered an admission of fault in a court of law. In 2005, Manitoba amended their Regional Health Authorities Act, as well as the Manitoba Evidence Act, to oblige health care workers to provide full disclosure to patients and families. In addition, these acts also protect their health care professionals from legal action, and following every critical incident, a mandatory internal investigation must be launched (CMAJ, 2009). In Quebec, Bill 113 was put into effect in 2002 and states that a user has the right to be informed of any adverse event and that any person working in an institution is under the obligation to report adverse events, as soon as they become aware of them (National Assembly of Quebec, 2002).
Case study
Patient X was admitted to the hospital with a previous history of coronary artery disease, abdominal cancer and gastroesophageal reflux disease. The patient had also had a Billroth 2 gastrectomy on a previous admission. The most current hospitalization was related to choledocholithiasis, for which the patient underwent an endoscopic retrograde cholangiopancreatography (ERCP). While in the lab, patient X experienced respiratory distress, agitation, vomiting and possible aspiration. The patient was admitted to the ICU in acute respiratory distress with an oxygen saturation of 90% while on 10 L of oxygen. The patient was also found to be tachypneic and tachycardic and was experiencing chest pain. In addition, patient X was noted to be febrile and hypotensive. Subsequently, the patient was intubated and given inotropic support with Levophed[R], broad-spectrum antibiotic coverage and was sedated with Propofol[R]. As well, central and arterial lines were inserted, following which a nasogastric (NG) tube was also placed and verified by the usual method of auscultation.
The following day, a chest and abdominal computerized tomography (CT) scan were ordered to rule out perforation. Gastrografin[R] was instilled via the NG tube. The results of the CT scan confirmed that there was a perforated viscus, and it also showed that the NG tube was positioned in the left lower lobe ofthe patient s lung. Both of these events are associated with high morbidity and mortality and, therefore, patient X was in critical condition, causing great distress and anxiety for the family.
The McGill University Health Centre (MUHC) Policy on sentinel events was used as a guide to support the team in disclosing these events to the family.
The MUHC policy on sentinel events
In complex situations such as the preceding case study, a standardized, multidisciplinary framework is needed to help guide health care workers. The case was deemed "sentinel" due to the seriousness and high mortality rate of both adverse events: the contrast infusion in the lungs and the perforated viscus. During this difficult and precarious time, the MUHC policy on sentinel events provided structure in order to fully understand the steps that needed to be taken.
As a forerunner to full disclosure in the past, the MUHC implemented a policy on sentinel events in 2005. The purpose of the policy was to "take proactive steps to reduce and prevent errors in order to improve patient care", and to "promote a culture of safety with an objective process that identifies system issues and does not assign individual blame" (MUHC Quality Management Department, 2005, p. 1).
Policy and procedures
Working in an environment that supports the full disclosure of adverse events within a systematic framework guides the health care unit to collaboratively and cohesively manage sentinel events, facilitate learning and improve patient safety.
Immediate steps outlined by the policy are to stabilize and treat the patient, inform the family of the current situation, provide appropriate support to the family and collect all relevant information. Steps taken within a few hours are to decide whether the event is possibly deemed sentinel, contact all appropriate personnel and devise a long-term care plan. The following day, a family meeting should be held with the interdisciplinary team where more information is provided to the patient and family, questions by the family are answered and all other concerns are addressed. Within a few weeks, further cause analysis takes place, recommendations for safety and practice improvement are made and any additional follow-up support is provided to the patient and family (MUHC Quality Management Department, 2005). Thus, it is clear that the MUHC policy on sentinel events assumes a process rather than a single conversation.
Throughout the disclosure process, there are certain strategies for communication that can help build and strengthen relationships between health care workers and families. These include using clear, straightforward words and terms; being open, sincere and apologetic; being culturally sensitive; and clarifying and ensuring understanding at a level where families feel comfortable while providing ample time for questions (Canadian Patient Safety Institute, 2008). These communication strategies can save much time and anguish in the long term.
The MUHC policy in practice
After the adverse events took place, the family was informed of the patient's condition. Patient X was then transferred to the operating room to repair the perforated viscus. The following day, a family meeting was held with the interdisciplinary team to review the previous day's events, explain the care plan, avoid speculation, express regret and arrange follow-up meetings. Several weeks later, this particular family found it helpful to have their relative, who was a physician, meet with the interdisciplinary team to gain further insight into the patient's health status, to facilitate a clear understanding of the events that took place and to further reassure the family that everything was being done to care for their loved one. This example shows how the policy is not carved in stone, but needs to be tailored to meet individual family needs.
After a lengthy stay in the ICU, the patient was stabilized and eventually transferred to a medical floor where the patient remained for several weeks before being discharged to a rehabilitation facility. Ongoing communication between the family and the health care team continued through telephone calls, emails and in person. As well, several follow-up disclosure meetings were held. The family admitted to having felt very frightened at the severity of patient X's condition. Over time and as the patient continued to stabilize, the family felt reassured and supported.
Health care professionals' role
"Promoting a culture of safety within organizations includes translating the lessons learned from sentinel events into concrete changes that will improve patient safety" (Daly, 2006, p. 28). In the above case study, the recommended practice for verification of NG tube placement by x-ray for all patients was implemented on the unit, as a safeguard to prevent the recurrence of similar situations. Lessons were learned from the traumatic events that took place and the patient's family was further comforted by the changes that were implemented.
The McGill model of nursing
Nurses play a pivotal role in helping families navigate through uncertain events. Nursing care can often make a difference between whether a family grows or deteriorates in response to these events. While the MUHC uses a policy to guide them in their disclosure of adverse events to patients and families, they also use a model of nursing, called the McGill model of nursing.
The McGill model of nursing is a situation-responsive, collaborative approach in nursing, which involves tailoring the quality and timing of interventions to "fit" clinical situations while working with a client's and family's perceptions (Gottlieb & Gottlieb, 2007). For instance, the health care workers involved in the case tailored the information given to the relative who was a physician differently than they did for the other family members.
By taking a health perspective, as opposed to solely an illness perspective, involvement with families is multidimensional, holistic, broad-based, and it works with the assessment and development of strengths and potentials. The team involved with this case helped the family identify their strengths by involving them in the care plan, thereby giving them a sense of control.
Lastly, nursing care adopts a long-term perspective by taking place over time and across different situations and settings. It involves assessing and promoting a client or family's readiness to engage with the health care professionals.
Implications for practice
Health care teams are currently moving towards a culture of full disclosure. In any health care environment, it is important to have a theoretical background to guide health care professionals in their interactions with patients and families. Specifically in critical care units, a guiding framework becomes paramount, as families are often in crises. In disclosing an adverse event, nurses are confronted with a range of emotions from families. A family-centred nursing model such as the McGill model of nursing provides a foundation for effective communication and collaboration. It is important to remember that disclosure is a process and not a single conversation. It involves mutual respect, compassion, honesty, courage, and patience (Disclosure Working Group, 2008). It also requires a team and not a single individual, and a series of conversations to complete all the steps necessary to understand, disclose, correct, and arrange for appropriate help or compensation for the injured party.
As health care professionals, nurses have a responsibility for and are accountable to the patients and families for whom they care. It is also important that they advocate for, and support the use of a full disclosure policy in their units. By enhancing the quality of practice with open, honest and effective communication, a culture of patient safety can be achieved.
Reflections from the unit
Informal conversations held with nurses revealed some of their thoughts and feelings regarding full disclosure when caring for patients and families who had experienced an adverse event. They found that it was difficult, but tried to be understanding, and felt that listening was an important aspect of their interventions. Many nurses relied on nonverbal cues to guide their interactions. On full disclosure, in general, nurses believed there must be diplomacy and not blame, and that families have a right to know if something has gone wrong. Most felt that full disclosure must be nonjudgmental and that the team must stay together, and work as one. Generally, the nurses felt supported by the leadership and by their colleagues, especially the medical residents, when it was necessary to disclose an adverse event to patients and families.
Student reflections
Students working with patients and families in the ICU voiced that patients and families often opened up to them. They had more time to offer and, therefore, made excellent listeners. When interacting with any family experiencing a crisis or uncertainty, often the best thing they felt they could do was listen.
Conclusion
"The process of disclosing errors requires courage, composure, communication skills and a belief that the patient is entitled to know the truth" (Healthcare Purchasing News, 2006, p. 8).
Throughout this experience, the authors always found it useful to consider "wouldn't we want to know" if faced with a similar situation. It is hoped that by sharing our experiences and reflections, we will succeed in encouraging nurses to enquire about and adopt their own centre's policy on adverse event disclosure.
References
Boyle, D., O'Connell, D., Platt, F.W., & Albert, R.K. (2006). Disclosing errors and adverse events in the intensive care unit. Critical Care Medicine, 34, 1532-1537.
Canadian Council on Health Services Accreditation. (2007). CCHSA patient safety goals and required organizational practices. Ottawa, ON: Author.
Canadian Medical Association Journal. (2009). High-profile death throws spotlight on error reports. Canadian Medical Association Journal, 180(9), 21-22.
Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON: Author.
Daly, M. (2006). The McGill University Health Centre policy on sentinel events: Using standardized framework to manage sentinel events, facilitate learning and improve patient safety. Healthcare Quarterly, 9, 28-34.
Disclosure Working Group. (2008). Canadian disclosure guidelines. Edmonton, AB: Canadian Patient Safety Institute.
Gottlieb, L.N., & Gottlieb, B. (2007). The developmental/health framework within the McGill Model of Nursing. "Laws of nature" guiding whole person care. Advances of Nursing Science, 30(1), 43-57.
Healthcare Purchasing News. (2006, June). Critical care's efforts to disclose medical errors and adverse events may not increase lawsuit. Healthcare Publishing News, p. 8.
Joint Commission on Accreditation of Healthcare Organizations. (2006). Sentinel Event Glossary of Terms. Retrieved from http://www.jointcommission.org/SentinelEvents/se_glossary.html
Levinson, W., & Gallagher, T.H. (2007). Disclosing medical errors to patients: A status report in 2007. Canadian Medical Association Journal, 177, 265-267.
McGill University Health Centre Quality Management Department. (2005). MUHC policy and procedure. Montreal, QC: MUHC Quality Management Department.
National Assembly of Quebec. (2002). An Act to amend the Act respecting health services and social services as regards the safe provision of health services and social services. Bill 113 (2002, Chapter 71). Quebec, QC: National Assembly.
Swiggum, S., & Wallace, G. (2009). Why a change in culture will improve patient safety. Canadian Medical Protective Association, 1 (1), 10-12.
About the authors
Elaine Doucette. RN, MScN, Faculty Lecturer, School of Nursing, McGill University, Montreal, QC.
Address for correspondence: Elaine Doucette, 3506 University St, Montreal, QC H3A 2A7. E-mail: elaine.doucette@mcgill.ca; Phone: (514) 398-2630
Sarina Fazio, BScN student, McGill University
Vanessa LaSalle, BScN student, McGill University
Christina Malcius, BScN student, McGill University
Jaclyn Mills, BScN student, McGill University
Taunia Rifai Archer, BScN student, McGill University
Jocelyne St-Laurent, RN, BScN, Nurse Manager, McGill University Health Centre
By Elaine Doucette, RN, MScN, Sarina Fazio, BScN student, Vanessa LaSalle, BScN student, Christina Malcius, BScN student, Jaclyn Mills, BScN student, Taunia Rifai Archer, BScN student, and Jocelyne St-Laurent, RN, BScN
Source Citation
Doucette, Elaine, et al. "Full disclosure of adverse events to patients and families in the ICU: wouldn't you want to know?" Dynamics 21.3 (2010): 16+. Academic OneFile. Web. 12 Aug. 2010.
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