In January, we drew attention to a paper co-published by our CEO, Jeff Driver, highlighting what Communication and Resolution Programs are and the challenges to implementing them; in February we focused on the key elements of disclosure and apology that are central to Communication and Resolution Programs; and in May, we discussed the value of Communication and Resolution Programs for everyone involved—patients, providers and healthcare institutions alike, in terms of improving patient safety, quality of care, and assuring that financial resources go towards patient care and not defending claims.
Today, I would like to explore the potential advantages and disadvantages of patient participation in what is known as the “Event Analysis Process.” In a follow-up piece, I will then explore how patients can be involved in the Event Analysis Process and potential legal implications from this.
What is the Event Analysis Process?
The Event Analysis Process usually involves an investigative team that conducts a thorough multidisciplinary investigation to identify the root-cause of an error or unanticipated event. It also recommends process and quality improvement changes to prevent similar errors in the future.
While the patient and family have always been the center of Communication and Resolution Programs and the disclosure process, the patient and patient’s family are typically not involved in the Event Analysis Process. Rather, the event analysis is typically done separately, and in parallel with the disclosure process.
What are the potential benefits of having patients and family involved in the Event Analysis Process?
In 2010, the Agency for Healthcare Research and Quality (AHRQ) awarded $19.7 million for demonstration projects combining patient safety improvement with solutions to reduce liability costs. One of the grants was focused on exploring how to take greater advantage of patients’ experiences to help hospitals change their systems and improve safety. Specifically, the project explored the question of whether patients and families should be involved in the Event Analysis Process and what is the best way to incorporate patients and family members into the Event Analysis Process.
The findings of the project suggested a number of potential benefits of having patients and their families involved in the Event Analysis Process. One primary benefit was in addressing patient needs.
After a medical error, or adverse event, most patients and families want to understand what happened, to hear an acknowledgment of responsibility and an apology, and to know what the institution or hospital is changing to prevent similar errors or outcomes in the future. While the disclosure process may be able to address such needs, patients may still be left waiting for some time before hearing any investigative results. By including patients and families in some capacity in the investigative process, they may gain a better understanding of the complexity of the investigative process and appreciate the transparency in identifying the root cause.
According to the project, other potential benefits of having patients and family involved in the event analysis are:
- Patients or their families may have information about an error that is not known to the hospital;
- Patient and family experience and insight may help prevent similar events in the future;
- The involvement could aid the healing process;
- Working together to understand what happened could reestablish the trust between patient and provider; and
- Even when it turns out that families do not have new information to provide, an institution shows respect to patients and families when conveying that patient and family perspectives are valuable to the investigation.
Although providers usually have a better grasp of the medical issues or hospital systems underlying an error, research shows that patients and family members can accurately identify errors and provide information. This may be, for instance, because they have witnessed the entire continuum of care involving multiple providers at various points, or because they were present during the event itself before any providers arrived at the bedside.
What are potential downsides to patient involvement in event analysis?
The report findings also noted some important reasons involvement in the Event Analysis Process may not be beneficial to patients:
- Patients and families may have no desire to be involved in event analysis or may not anticipate the potential psychological stress of participating;
- Patients and families may feel intimidated by the medical jargon and complexity of the care involved;
- They may feel pressure to provide missing information;
- The grieving process may be intensified by having to recount or relive particular phases of care;
- There is potential for patients or families to blame themselves in retrospective analysis;
- And patients may develop a heightened fear of the possibility of future errors.
As for providers, who can be the forgotten “second victim” in the emotional fallout of an error, patient involvement in event analysis could potentially have the following downsides:
- Providers could feel uncomfortable discussing the error, fearing blame and litigation, undermining the need for transparency in a Communication and Resolution Program;
- And providers could also potentially incur greater legal risks not only with increased patient vigilance, but because of the potential loss of certain legal protections.
Ultimately, the decision of whether patient and family involvement in the Event Analysis Process is appropriate depends on not only the institution’s Event Analysis Process, but more importantly, on patient and family needs. Initial findings from a federal demonstration project indicate that involving patients has great potential to not only meet such needs, but also improve the quality and safety of health care. I will explore how patients can be involved in the Event Analysis Process and potential legal implications from this in a follow-up piece.
By Florence Wang, M.D., J.D.
Florence graduated from Stanford Law School in 2014. Prior to law school, she studied medicine and received her M.D. from New York University School of Medicine. Dr. Wang practiced in women’s healthcare at a free clinic in Los Angeles and is interested in health law.