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Follow a Plan When Explaining Adverse Event

Donna Young

The University of Virginia Health System (UVHS) at Charlottesville has implemented a new plan for managing adverse patient events.

Abraham Segres, UVHS risk management director, said the plan is an attempt to coordinate communication among the hospital’s various disciplines after a serious adverse event occurs.

UVHS initiated the plan, he said, after a family sued the facility for fraud, alleging it had attempted to "cover up" an adverse drug event.

Segres said the adverse event involved a "monitoring error in the recovery room where there was a question about the amount of medication that had been administered to the patient following surgery."

Segres said the family believed it had received conflicting information from various care providers and staff members involved in the case.

"A well-intentioned physician immediately communicated to the family, from his perspective, what had happened—before the hospital had a chance to look at the facts," he said.

The suit ended in an out-of-court settlement, Segres said.

UVHS assessed how the aftermath of the adverse event was managed. The hospital determined that communication to the family about the event was not well coordinated, Segres said.

UVHS initiated its plan in January and has since been "tweaking" it, Segres said.

"We want to make sure the information we are providing to the family or patient is prompt, accurate, and factual," he said.

Segres said now, when a serious adverse event occurs, all of the institution’s care providers and staff members involved with the patient, in addition to someone from risk management, meet within a matter of hours "to compare notes."

"Before we have a conversation with the family, we determine what we know and who is the best person to communicate with the patient or family," Segres said.

"If it involves a medication error, we need to know if the nurse administered [the drug] consistently with what the physician wrote and if [the order] was filled correctly by the pharmacy," he said.

Segres said the person designated by the facility to discuss the details about the adverse event with the patient or the family is not always the physician.

"It might be a social worker or someone who is knowledgeable about the event or who has a good rapport with the family," he said.

Segres said when a health system designates a person to act as the primary communicator to the patient or the family, it takes the pressure off other care providers and staff members involved in the case.