Bad Outcomes Task Force

Bad Outcomes Task Force – Patient Adverse Events Standard Operating Procedure (SOP)

As used in this procedure, an adverse event is defined as patient suicide within or outside the hospital setting, violence by a patient within or outside the hospital setting, a life threatening reaction to a psychiatrist-ordered medication, physical assault of a resident or other staff member by a patient, stalking of a resident or other staff member by a patient, crimes or threats. An adverse event may also include any other patient care-related event that causes a resident significant distress that does not fall into one of the above categories.

 

Goals of This SOP:

1) Improve processes related to notifying residents that an adverse event has occurred, ideally with a universal, cross-site, program-wide standard operating procedure

2) Ensure that residents are aware of – and have access to – resources for both professional and personal support should a patient whose care they have been involved with experiences an adverse event

3) Clearly define expectations for residents with respect to how they are to respond to an adverse event and expectations for appropriate program and clinical staff in involving residents in site-specific processes related to adverse events

4) Ensure residents have the opportunity to participate in site-specific interventions related to an adverse patient event, including quality improvement initiatives and staff debriefing/processing events

 

SOP:

1) After an adverse event has occurred – and appropriate clinical staff (e.g., unit medical director, faculty attending) have been notified – residents involved with the care of the patient, as well as Dr. Brenner, will be notified by the site of the adverse event directly as soon as feasible. Dr. Brenner will inform the chief residents so the chiefs can reach out to the affected resident as well as help coordinate the initial meetings.

2) The involved resident(s) are to immediately contact Dr. Brenner and, if desired, the chief residents to alert him/them of the adverse event and meet as soon as feasible to debrief.

2a) The involved resident(s) will be offered a brief reprieve from call and other clinically-related duties outside of usual business hours for a defined amount of time (our group has proposed 5 days). This is to be coordinated by the chiefs and class representatives.

2b) The involved resident(s) will be provided direct guidance from the attending at the affected site with respect to how to proceed with the case, particularly with respect to medicolegal concerns: Can/should family of the affected patient be contacted? Can the resident(s) review the patient’s chart as an educational activity? Should the case be discussed at all?

3) The involved resident(s) will be given the opportunity to participate in a treatment team – including involved clinical and support staff – debrief of the case; we propose that this should occur within 1 week of being notified of an adverse event

4) The involved resident(s) must have a check-in meeting with Dr. Brenner or other identified support person within 1 week of being notified of the adverse event. This may be initiated by the resident, Dr. Brenner, or the chief residents, but the important outcome is that the affected resident has an early opportunity to meet with Dr. Brenner.

5) If appropriate and desired, the involved resident(s) can be referred for formal treatment (e.g., psychotherapy) following the event

6) A follow up meeting with Dr. Brenner or other identified support person (chief resident, attending physician) must occur within 1-2 months of the adverse event. This should be scheduled at the conclusion of the initial meeting.

7) The involved resident(s) will be provided the opportunity to participate in any quality improvement activities that occur as a result of the adverse event, if desired (e.g., root cause analysis)

8) Future meetings with Dr. Brenner or other identified support person can occur at the discretion of the resident and designated support person