● Staffing: The psychiatric unit employed one registered nurse, one nursing assistant, and one social worker who covered 25 patients and their families. Lee (interpreter) worked two days a week, Wednesdays and Fridays. ● Policies: The policy for assessment and treatment of suicidal patients did not address bedsheets or towels, room assignment, monitoring, or structured assessment of suicidal intent. At the conclusion of the root cause analysis, the staff discussed some initial ideas for a follow-up action plan, assigning specific responsibilities to individuals. ● A structured suicide assessment would be administered to all patients immediately upon admission. Dr. Gordon (psychiatric resident) agreed to examine the literature to find a state-of-the-art instrument and discuss which instrument was best with the director of the residency program. Dr. Gordon promised to share his findings with the group within a week. ● Suicidal patients would be assigned rooms across from the nurses’ station; access to bedclothes and towels would be restricted; a single individual would have responsibility for monitoring a suicide watch. Terry (head nurse) assumed responsibility for developing these policies and agreed to share them with the group within 10 days. ● Lee (interpreter) suggested that interpreters be on call on an as-needed basis, rather than working assigned days. He also offered to present an in-service training to staff on Cambodian culture. Participants welcomed the offer of an in-service training. Terry (head nurse) agreed to discuss the possibility of interpreters being on call with the hospital’s vice president of clinical services and agreed to report her findings to the group at their next as-yet-to-be-scheduled meeting. Error Disclosure Reporting mistakes so that learning occurs is one important aspect of transparency. Error disclosure or full disclosure—being honest and open with clients and their families when things go wrong—is another task altogether and is often difficult for providers and frontline staff (Al Madani et al., 2020). Full disclosure is defined as communication between a healthcare professional and patient or family member about an adverse event. Full disclosure is a particular type of communication that provides specific information and requires specific skills (Truog et al., 2011). It includes: ● An acknowledgment of the error ● An explanation of what happened, including connections between the mistake and possible outcomes ● A sincere apology When information is given with compassion and presented in clear, simple language, patients and families respond positively when mistakes are disclosed (Boothman et al., 2009). There is widespread agreement that full disclosure is the ethical action Case Study 3 Charlie, age two; his mother; and his siblings (a three-year- old brother and infant sister) entered a shelter for victims of domestic violence while police searched for his father. His Romanian mother, in her early 20s, spoke little English, and on the family’s second day in residence, workers contacted Child Protective Services because the mother was neglecting to change the baby’s diapers and interacted with her sons either by yelling at or hitting them. Child Protective Services placed Charlie and his siblings with three separate foster families, all of which were interested in adoption. Attempts to reunite the biological family continued for three years. Each month the foster families would bring the children to visits with their parents, supervised by a court- appointed guardian ad litem. Each child received mental health services at a different agency. Christie, a psychologist from the
● Participants agreed that additional staffing was unlikely, given the most recent round of budget cuts. The participants agreed to meet again in two weeks and then on a monthly basis to evaluate the effectiveness of the action plan,
making changes as needed. Case Study 2 Discussion
Given the complexities of this case, root cause analysis is an important tool; however, it is only a beginning step on the journey to a culture of safety. Root cause analysis, like traditional efforts to detect adverse events (such as incident reporting systems), relies on voluntary reporting. While the idea of a blameless, voluntary reporting system is beyond the scope of this course, it is worth mentioning because it supports organizational learning, and learning is key to a culture of safety (Peerally et al., 2017). Supporting the providers in this case, Jenn and Elise, while helping to educate them about safer practices on the unit is a balancing act. Employees from the Quality Improvement Department need to walk a fine line, being mindful of accidently shaming the providers and being true to their improvement process mandate. Events that cause harm are rapidly investigated and analyzed to prevent future harm, while, for the purpose of designing safer systems, near misses and error-prone conditions are tracked and trends are noted. An organization that is well on its way to a culture of safety encourages everyone—patients, family members, and staff—to report adverse events, near misses, and error-prone conditions. A root cause analysis is intended to identify system vulnerabilities so that they can be resolved, or at least mitigated; it is not to be used to address individual performance issues, since individual performance deficits are symptoms of larger systems-based flaws (National Patient Safety Foundation, 2015). to take, increasing pressure from government and regulatory agencies to disclose, and empirical evidence that disclosure reduces lawsuits, yet full disclosure is far from standard practice in healthcare, and many victims of medical error never learn of the mistake that harmed them. Transparent communication after medical errors increases when physicians work in a culture of trust and receive training in how to disclose errors (Etchegaray et al., 2012). Clinicians who work in a blame culture have difficulty discussing errors with patients and families, out of a lack of training and awareness, despite the fact that error disclosure can increase the community’s confidence and trust in healthcare providers (Al Madani et al., 2020). Worldwide, providers are obligated to receive training in respect to error disclosure, although researchers argue that evidence may be lacking that this practice, which is required by accreditation bodies, does in fact increase the occurrence of disclosure practice to patients and families (Al Maadani et al., 2020, Schwendimann et al., 2018). hospital’s outpatient psychiatric clinic, worked with Charlie and his foster parents, Donna and Dan, throughout the reunification period. Two different agencies provided services to the other children and their foster families. These agencies had high staff turnover, and each year a new social worker was assigned. Throughout the three years, Charlie’s mother attended parenting classes and had monthly supervised visits with her children. After completing his jail sentence, Charlie’s father agreed to participate in an anger management program. Despite these interventions, reunification attempts were unsuccessful. Charlie’s mother demonstrated minimal improvement in her parenting skills, and her counselor believed future change was unlikely. Although Charlie’s biological father did attend the required anger management sessions, his therapist believed his sole motivation was to avoid further
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