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Health Care Manage Rev. 2011 Apr-Jun;36(2):114-23. doi: 10.1097/HMR.0b013e318200f916.

Successful remediation of patient safety incidents: a tale of two medication errors.

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  • 1Department of Health Administration and Policy, College of Health and Human Services, George Mason University, 4400 University Drive, MS 1J3, Northeast Module I, 121, Fairfax, VA 22030, USA. lhelmche@gmu.edu

Abstract

BACKGROUND:

As patient safety acquires strategic importance for all stakeholders in the health care delivery chain, one promising mechanism centers on the proactive disclosure of medical errors to patients. Yet, disclosure and apology alone will not be effective in fully addressing patients' concerns after an adverse event unless they are paired with a remediation component.

PURPOSE:

The purpose of this study was to identify key features of successful remediation efforts that accompany the proactive disclosure of medical errors to patients.

APPROACH:

We describe and contrast two recent and very similar cases of preventable medical error involving inappropriate medication at a large tertiary-care academic medical center in the Midwestern United States.

FINDINGS:

Despite their similarity, the two medical errors led to very different health outcomes and remediation trajectories for the injured patients. Although one error causing no permanent harm was mismanaged to the lasting dissatisfaction of the patient, the other resulted in the death of the patient but was remediated to the point of allowing the family to come to terms with the loss and even restored a modicum of trust in the providers' sincerity.

PRACTICE IMPLICATIONS:

To maximize the opportunities for successful remediation, as soon as possible after the incident, providers should pledge to injured patients and their relatives that they will assist and accompany them in their recovery as long as necessary and then follow through on their pledge. As the two case studies show, it takes training and vigilance to ensure adherence to these principles and reach an optimal outcome for patients and their relatives.

PMID:
21317663
[PubMed - indexed for MEDLINE]
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