August 6 , 2007

Plan for the Panic
By Patrice L. Spath, BA, RHIT
For The Record
Vol. 19 No. 16 P. 24

Sentinel events are rare, but when they do occur, it is paramount that healthcare organizations respond quickly but cautiously.

A normal kidney is removed from a patient following an error in the radiology department. The digital images of another patient’s CT scan had been inadvertently linked to the wrong patient’s electronic record. The surgeon involved discusses the error with the patient and his or her family. The medical director reports the event to the state health department. Within two days, the media learns of the unnecessary kidney removal, and the incident makes the national news. Leadership in the hospital panics—what should be done to correct the underlying problems so a similar event can be avoided? How can the hospital minimize negative publicity?

Fortunately, a significant adverse event such as the one described above is an uncommon occurrence. However, because of its rarity, when such an event happens, it can cause a barrage of urgent and unexpected circumstances that allow little time for caregivers to think, organize, or plan appropriate actions. For this reason, it is important for healthcare organizations to have a clearly defined sentinel event action plan. The plan should spell out the immediate steps to be taken in addition to the process that will be followed to uncover and correct the event’s root causes.

Patient and Family First
The first priority following a sentinel event must be the patient and his or her family. When a serious adverse event occurs, sincere sympathy and compassion expressed to the patient and/or the family are often the most important response to help diffuse a potentially volatile situation. Rather than taking a defensive stance against accusations of substandard care, the healthcare team should refrain from castigation or infighting and immediately begin the following positive measures:

• Assess the situation and communicate with the patient and/or the family.

• Determine who from the healthcare team will discuss the event, with whom (the patient and/or responsible family member), and when.

• Maintain contact with the patient and/or family for questions. Repeated requests for an explanation of the event is a common reaction of angry or anxious patients and family members.

• Organize a family meeting if several relatives are involved in the patient’s care or treatment decisions are complicated.

• Empathize with the patient and family and offer emotional support. If appropriate, apologize for the patient’s distress without admitting liability.

• Attempt to reconcile opposing perceptions of what has occurred.

• Accept responsibility for the follow-up of serious complaints, but do not accept or assign blame or criticize the care or response of other providers.

Individual caregivers are rarely experienced in dealing with an adverse occurrence. The risk manager and the facility’s legal counsel should be available to advise physicians and staff about ways to communicate information in a manner that is forthright and comforting but which does not unintentionally alarm, misinform, or render judgment.

Identify Key Players
Although every situation is different, there are general crisis management guidelines to keep in mind. The time period immediately following a sentinel event (the “panic” phase) requires crisis management interventions. Many organizations have a designated crisis management team for handling other types of disasters, and this same team could be activated following a significant sentinel event. At a minimum, the team should include the president or CEO, head of public relations, senior manager in charge of the involved clinical area, risk manager or patient safety officer, the organization’s attorney, and anyone else who may shed light on the clinical situation, such as physicians and eyewitnesses.

Gather as much preliminary information as possible and as quickly as possible. Information vital to reconstructing events may be accidentally altered or discarded, preventing determination of cause. The highest priority for the primary caregivers must be the patient’s care, so responsibility for this preliminary data-gathering step must be assigned to others. Typically, the facility’s risk manager or patient safety/quality director serves as the principal investigator. However, outside of normal working hours, the house supervisor should be charged with performing this preliminary investigation.

Make a list of all the key people within the organization who need to be contacted in case of a sentinel event. Typically, this group includes any members of the crisis management team. The list can also be used to document the contact results (ie, what time the person was reached, what course of action was recommended, and the person’s responsibilities). Another list of names and numbers of key people outside the organization should also be maintained.

Be sure to involve legal counsel early in the process. Ask for guidance in discussing the situation with the patient and/or family, how to prevent disclosure of potential libelous information, and how to handle media relations.

Document and Investigate
Assign the most involved and knowledgeable caregiver(s) to record statements about the event in the patient’s record. They should also record what action was taken and any follow-up needed or performed as a result of the incident. Avoid writing in the patient’s record any information unrelated to their care (eg, “incident report filed” or “legal office notified”). Do not erase or obscure information in the patient’s record. If a correction is necessary, lightly cross out the original entry and initial and date changes. Additions to and explanations of notations on the record can be made to explain issues where professional judgment was involved.

An incident report should be completed by the person who discovered or witnessed the event or whoever has firsthand information. If staff need help in completing the report, they should be encouraged to seek assistance from their supervisor. Since the incident report is not part of the patient’s record, it can be reviewed and revised until it accurately reflects the event. Incident reports should be forwarded to the risk manager within 24 hours or within the time frame established by the organization.

The Joint Commission’s standards are silent on how quickly sentinel event investigations should be initiated. However, the standards do require that the root cause analysis be substantially completed within 45 days. To meet this deadline, facts surrounding the event need to be gathered as quickly as possible. The fact-gathering process involves the following:

• Collecting physical evidence. Conducting initial interviews with those involved will help the investigator identify the physical evidence, if any, that needs to be gathered. Examples of physical evidence may include equipment, materials, and safety devices. If equipment or materials were a causal factor in the event, it may be important to document the preaccident and postaccident positions of event-related equipment/materials. Inspect all the physical evidence and document the findings.

• Collecting documentary evidence. Documentary evidence can provide important data and should be methodically preserved and secured. This information may be in paper or electronic media.

• Identifying and interviewing people directly and indirectly involved in the event. Keep in mind that people’s memories, as well as their willingness to assist, can be affected by the way they are questioned. It’s important that the process not be viewed as an interrogation. The people directly involved in the event should feel they are part of the investigation process and their input from initial interviews and follow-up interviews will be used to prevent future events, not to assign blame.

Manage the Media
If it is likely the event will become public knowledge, the sentinel event crisis management team should determine the appropriate message that will be given to the public. This is where “tell it all, tell it fast, and tell the truth” begins. It is always best when a mistake has been made to admit it immediately and begin doing whatever is possible to reestablish credibility and confidence with internal and external audiences. While the foremost goal is protecting the integrity and reputation of the organization, don’t try to lie, deny, or hide the organization’s involvement. Ignoring the situation will only make it worse. When deciding on a public position, it is important to view the event from the consumer’s perspective.

The public relations director should work with the crisis management team to draft a written statement for the media. Include the known facts and the organization’s responses, if they have been determined. Anticipate the questions that will be asked by the media and try to answer them in the statement. Issues most likely to be raised by the media include the following:

• Who or what is the cause of the sentinel event?

• What is the extent of the patient’s injuries?

• What is the organization’s immediate and long-term response to the event?

• Has this or a similar patient incident happened before in the facility?

General guidelines for handling the media following a significant patient care event are listed in Figure 1.

Designate someone as the primary spokesperson to represent the organization, make official statements, and answer media questions. A backup to the spokesperson should also be identified to fill the position in the event that the primary spokesperson is unavailable. In addition to the primary spokesperson and the backup spokesperson, individuals who will serve as technical experts or advisors should be designated. These resources may include a physician, nurse, chaplain, or anyone in the facility who can answer specialized questions. Technical experts should have proficiency in their field and be available to supplement the spokesperson’s knowledge.

The public relations or communications department may need to be supplemented with competent people who can answer phones and escort media representatives if necessary. It is essential to have calls by the media answered promptly. As soon as possible, a prepared statement should be issued that says something such as, “Facts are still being gathered, but there will be a press conference shortly. Give me your name and number, and I will call you back to let you know when.” A log should be established to record all telephone calls from the media or other parties inquiring about the crisis—this will help to ensure that callbacks are not overlooked.

Reporters may ask to speak to physicians or staff involved in the event. It is best to restrict all interviews to the primary or backup spokesperson or a technical expert. Thoroughly preparing these people will help minimize surprise questions by the media. Accomplish this by preparing a list of common questions and answers for the spokespersons. This list is for internal use only and not for distribution outside the organization.

Provide media representatives only the facts that have been gathered from reliable sources and confirmed. Don’t overreach or speculate. Often, it is sufficient for the organization’s representative to do nothing more than show concern for the patient and family during the first interaction with the press. Have a prepared statement on hand that can be used to provide an initial general response to the media when knowledge about the sentinel event first becomes known.

As the situation progresses and new information and facts become available, it is also advisable to develop prepared statements for the spokesperson to use at the onset of any media interview, briefing, or news conference. These prepared statements can also be read over the telephone to reporters who request information or sent by fax or e-mail upon request.

Evaluate Preparedness
An organization’s sentinel event crisis management plan should be considered a work in progress, with the need for periodic modification, adjustment, and updating. If an organization has the unfortunate opportunity to test its plan, all elements should be analyzed to determine the effectiveness of each step in resolving the situation. Patient well-being must always be the first priority. Ideally, media portrayals of the facility can be kept in the best possible light.

This evaluation, which should begin as soon as possible after the immediate sentinel event crisis has been resolved, may include conducting interviews with involved physicians and staff. If the event became public, analyze the content of newspaper clippings and radio/television broadcasts to assess how your organization’s image was portrayed during the crisis. Modifications should be made in the plan where the needs of the situation were not met effectively.

— Patrice L. Spath, BA, RHIT, is a healthcare quality specialist, author of Investigating Sentinel Events: How to Find and Resolve Root Causes, a partner in Brown-Spath & Associates (www.brownspath.com), and an assistant professor in the department of health services administration at the University of Alabama in Birmingham. She may be reached at patrice@brownspath.com.

Resources
Discussing Unanticipated Outcomes and Disclosing Medical Errors is an instructional video written and directed by John Banja, PhD, an associate professor at Emory University’s Center for Ethics. Free for viewing and downloading here.

“Administrative Guidelines for Response to an Adverse Anesthesia Event.” A suggested series of steps that should be taken to minimize patient injury to and identify the cause of an adverse event. Available from the Anesthesia Patient Safety Foundation here.

Figure 1
General Guidelines for Media Relations Following a Sentinel Event

Be Accessible

• Don’t avoid the media.

• Make the spokesperson available at their office and home.

• If it is too soon to release accurate information, announce a time within the next few hours when a statement will be issued or a news conference held. Once the time has been announced, do not release information to any media until that time.

• Return media calls as soon as possible. If the information requested is not available, explain why and when it may be available.

Have One Voice

• Your organization’s official spokesperson should coordinate the dissemination of information to the media and other internal and external audiences.

• No one except the designated spokesperson should speak to the media. Allowing different people to represent the organization may send mixed messages and cause confusion.

• When possible, release comprehensive statements in writing to avoid misunderstanding or misinterpretation.

• Establish the designated spokesperson as the best source of information.

Information Disclosure

• An immediate response is vital.

• Release only verified information about the sentinel event.

• If you must say “no comment,” explain why.

• Do not idly speculate if an answer is unknown.

• Do not extrapolate. Keep answers short and to the point.

• Don’t leave rumors unaddressed.

• Don’t stonewall the media—it may lead them to other information sources that may offer negative, inaccurate, emotional, and incomplete details.

• Admit responsibility for the event when appropriate.

• Explain what actions are being taken within your facility to rectify the situation and prevent recurrence of similar events.