Risk Management
&
Disclosure
Kirsten Thomson,
November 2012
My Portfolio
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Patient Safety Learning System (PSLS)
Risk management
Education affiliation agreements
Insurance
PSLS
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Add and deactivate users
Provide training
Provide final approval to all events
reported in system
Trending and analysis
Review for potential claims
Risk Management
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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
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Our “insurer” and risk advisors
Provide NH with liability, property,
directors & officers, and some crime
coverage
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Physicians covered by HCPP only for
administrative work
We report serious adverse events
They provide legal counsel
Reporting Events
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PSLS
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Department channels
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Can only be done on computers connected to
the NH network
Department head, chief of staff, department
manager
Directly to me
What kinds of events to report
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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.”
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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”
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Events that you might report to CMPA
“Must Report” Events
Surgical events
1. Surgery performed on the wrong body part
2. Surgery performed on the wrong patient
3. Wrong surgical procedure performed on a
patient
4. Unintended retention of a foreign object in a
patient after surgery or other procedure
5. 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 person
10. 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 events
12. 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 events
19. 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 Events
24. 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?
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Critical incidents undergo quality review
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Reported to HCPP; legal counsel may be
assigned
Non-critical incidents are tracked and
trended
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PSLS no harm events
Disclosure
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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
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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.”
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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
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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)