How can we improve error and apology practice? A panel discussion with patients and leaders

Medical error is the third leading cause of death in Canada. When adverse events causing death or serious disability occur in hospital, healthcare systems must strive to address that error while respecting the needs of harmed patients and families. Often when a patient is injured as a result of a medically adverse event, that patient is perceived as a threat and liability. This perception of an injured patient as a threat determines how the "system" interacts with the patient. 

 

One of the objectives of NHLC 2020 is to share issues of common interest in the areas of accountability, effectiveness and transparency in the health system; consequently, understanding best practices in post-error practice is critical. The purpose of this panel is to describe recommended practice for disclosure, investigation, and apology after a patient safety incident. This panel will include representation from Nova Scotia Health Authority Quality branch leadership, Patients for Patient Safety Canada, and a harmed patient. The patient will share a narrative regarding serious radiology error, and what she experienced moving through the system. Quality leadership will share how they intervened in the case to ensure more appropriate resolution and broader systems learning. Patients for Patient safety will share their four principles of involving and supporting harmed patients in the post-error investigation process - the principles shared with various Ministers of Health during recent provincial meetings. 

 

We hope to illustrate the "do's" and "don'ts" for managers and clinicians when responding to patients and families after a serious adverse event, underscoring the importance of patient engagement. We will share a variety of online resources developed by the Canadian Patient Safety Institute for this purpose. 

 

As this panel will have two patient representatives, as well as a patient moderator, along with a healthcare leader, our panel uniquely illustrates the "Patients Included" vision of NHLC. 

 

Panelists 

Robin McGee – Patient Representative, Patients for Patient Safety Canada 

Colin Stevenson – VP Health Services, Quality and System Performance, Nova Scotia Health Authority 

Linda Hughes – Canadian Patient Safety Institute 

 

Moderator 

PJ Mierau - Patient Critical Co-op