Medical Malpractice 101: Patient Needs to Be First, Last, and Everything In Between

Larry Smith, Vice President of Risk Management at MedStar Health, is a true pioneer – one of a small number of leaders in healthcare who have developed early communication and resolution programs when harm from medical error occurs. Programs like University of Michigan led by Rick Boothman and Susan Anderson, University of Illinois led by Tim McDonald and Nikki Centomani, and MedStar Health led by Larry Smith and Steve Evans have long moved from a “deny and defend” approach to medical errors to one of open and honest communication. These programs have been able to bring closure and healing to all parties involved while using the court system and the long, difficult battles that result where no really wins except maybe the attorneys as a last resort.

This week, Larry recruited not only his own team of insightful and skilled Risk Managers, but also plaintiff attorney, Paul Bekman, Esq., defense attorney, Michael Flynn, Esq., and the Honorable Howard Chasanow, former Maryland Supreme Court Justice and now a full-time mediator, to participate in MedStar Health’s Quality, Safety & Risk Management retreat. It may sound like an unlikely gathering of peers to many, but for Larry, the only way to move towards the “just culture” required of high reliability organizations is to continue to unite those whom often seem disunited.

As the panel of experts shared what really occurs in court rooms in the aftermath of a medical error, all attendees gained a deeper understanding of the complexities inherent to managing a healthcare system. At a time when patients and caregivers are caught up in the pain, uncertainty and fear related to what is often a life-changing event, the medical-legal piece can either remove, or compound, the emotional, physical and financial costs involved. One thing many of the attendees learned was that when a patient forfeits control, and ultimately a say in the final decision of such an intimate and painful event, to a jury of peers with what can be at times an attorney not well-versed or well-intended when it comes to medical-legal matters, additional problems can be created for all involved. Claims filed often cost health systems millions of dollars, and patients many times do not receive what they truly deserve when cases are handed over to the courts. Judge Chasanow was truly inspirational and shared that true healing for all can be found through skillful mediation led by those knowledgeable in the intricacies of medical harm events–especially when led by those who have the patient and family’s best interest as the top priority. He also shared the amazing healing power that can result from two words –“I’m sorry”. When offered in a sincere and meaningful manner, anger and tension seem to dissipate and true progress towards closure and healing through mediation can begin for all.

Moving forward, we have two options:

Or a second option. A few years ago, Transparent Health put together a short trailer for a longer piece of work that sums up another approach to managing medical errors and the harm that can come from them. When harm is managed openly, honestly and with transparency, healing can begin. Here is that short clip:

Healthcare remains at a crossroad. If we are to truly achieve a Culture of Safety and drive towards Zero Harm, we must embrace open and honest communication, practice just culture principles that balance systems and process breakdowns with reckless personal accountability, and follow the wise words of Carole Hemmelgarn who so eloquently said it should always be “Patient first, last and everything in between”.

Advertisements

4 Comments on “Medical Malpractice 101: Patient Needs to Be First, Last, and Everything In Between”

  1. Patty CPS says:

    Just curious was there a patient/family member that Sued on the panel? P

    Sent from my iPhone Patty

    >

  2. Kathy Day RN says:

    Rosemary Gibson can speak for me any day.
    This conversation had been needed for years. I remember when I worked as a hospital nurse, how quickly and efficiently we were shut up by our employers if anything went wrong with a patient. We were not “allowed” to talk to each other (employees) and especially not to the patient or their family. This secrecy, denial and silence accomplished nothing except grief, anxiety and sorry over sometimes very horrid medical error/neglect and harm. Nobody learned anything when things were handled that way…and most importantly, the patient and family never got answers and support that they deserved, as quickly as possible. Including the patient in Root cause Analysis or “internal investigations” from the beginning, and keeping them updated on findings is the only humane and compassionate way to handle healthcare harm.

    • Kathy,
      Thanks so much for sharing your thoughts. I have been blessed in that Rosemary has been a good friend and mentor for many years. Her insights and leadership helped us shape our program as well as many others across the country like Rick Boothman and Tim McDonald who have been leading change and doing the right thing when unintentional harm occurs for a long time now. You are right – the second harm can be as bad as the first.
      Regards,
      Dave


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s