Education
Communicating about Unanticipated Outcomes and Medical Errors
May 17, 2002
There has been an emerging ethical consensus as well as increasing accreditation and
legal mandates that health care providers and organizations communicate forthrightly
with patients and families about significant unexpected outcomes, medical errors,
and accidents. The July 1, 2001 JCAHO patient safety standards, under the patients’
rights and organizational ethics standards,
states that “patients, and when appropriate, their families must be informed
about the outcomes of care, including unanticipated outcomes.”
Objectives:
- Provide a legal perspective on the full disclosure of significant unanticipated
outcomes and errors to patients and families, and the potential impact that
such disclosure could have on medical professional liability.
- Gain insight from hospitals and health systems that have addressed the issue
of disclosure and how they continue to improve upon the process as they’ve
learned lessons along the way.
- Offer effective strategies for initiating these discussions with patients and
families, recognizing the issues that must be addressed to make these conversations
healing for all parties involved.
- Provide a rare glimpse into press hospital relations, and ways they can effectively
communicate regarding unanticipated outcomes.
- Provide organizations with practical strategies to address the JCAHO standard requiring
patients and families be informed of unanticipated outcomes.
Agenda:
8:15 am – 8:45 am Registration and Continental Breakfast
8:45 am - 9:15 am Welcome and Opening Remarks
John Noble, MD
Chair, Joint Commission on Accreditation of Healthcare Organizations
Co-Chair, Massachusetts Coalition for the Prevention of Medical Errors
Lucian Leape, MD
Adjunct Professor of Health Policy
Department of Health Policy and Management, Harvard School of Public Health
9:15 am – 10:00 am Ethical Aspects of Disclosure
John Combes, M.D.
Senior Medical Advisor
Hospital and Health System Association of Pennsylvania and American Hospital Association
10:00 am – 10:45 am Legal Aspects of Disclosure
Philip Crowe, Esq.
Crowe & Mulvey
William J. Dailey Jr., Esq.
Sloane & Walsh
10:45 am - 11:00 am Break
11:00 am – 11:30 am A Family Member’s Perspective of Disclosure
Roxanne Goeltz
Roxanne Goeltz, is an air-traffic controller whose brother Mike died of a medical error
in 1999. She will share her and her family’s experience and discuss her perspective
on the process of disclosure.
11:30 am – 12:15 am Hospitals & the Media: Strange Bedfellows
Larry Tye
Larry Tye, who worked as a medical correspondent for the Boston Globe for 15 years,
will explain the perspective of the media in looking at issues of errors and ways that
hospitals and the media can collaborate to advance error prevention.
12:15 pm – 1:15 pm Lunch
1:15 pm – 1: 45 pm DPH’s Aspect on Disclosure
Nancy Ridley, Assistant Commissioner, Department of Public Health
1:45 pm – 3:00 pm Hospital Strategies for Disclosure-Panel Discussion
Panel Moderator - Leslie Kirle
Senior Director Clinical Policy & Patient Advocacy, Massachusetts Hospital Association
Barbara Lightizer MS, MA, CPHRM, DFASHRM
Director Performance Improvement & Risk Management
St Elizabeth Medical Center
Maureen Connor RN, MPH, CIC
Director Risk Management
Dana Farber Institute
Connie Crowley Ganser MS, RNC
Director QI, Risk Management & Education
Children’s Hospital
Co-Chair, Massachusetts Coalition for the Prevention of Medical Errors
Ruth Fitzpatrick
Risk Manager
Fairview Hospital
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