0:00

Before we go, uh, further, I did want to cover a,

0:04

a common understanding of the definition of error.

0:08

Uh, this is the definition put forward by the Institute

0:11

of Medicine, whereby error

0:13

and error is defined as an unintended act, either

0:16

of a mission or commission,

0:18

or one that does not achieve its intended outcome.

0:22

It can be an, uh, issue of planning or execution.

0:26

It can represent an unwarranted failure

0:29

to accommodate the standard of care.

0:31

Although it's important to recognize that in radiology

0:34

and diagnostic medicine, often adverse events

0:37

and errors occur even when the practice is

0:40

within the standard of care.

0:42

It can represent a failure to establish an accurate

0:46

and timely explanation of the patient's health problems

0:49

or communicate that explanation to the patient.

0:53

And this can occur as often within the standard of care.

0:56

In radiology, there is a lot of, uh,

1:00

there is an important distinction to be made

1:02

between adverse events that are preventable

1:04

and adverse events that are un unpreventable, those

1:07

that are preventable, being errors to kind of

1:11

as a general guideline

1:13

for when an adverse event is preventable, uh,

1:16

the question can be asked, is it related to individual

1:20

or systems lapses, or very commonly both.

1:23

And the answer is yes,

1:24

that's a preventable adverse event and error.

1:28

And the question can be asked,

1:29

can interventions be implemented to prevent the future

1:34

likelihood or mitigate the future

1:35

of likelihood of such events?

1:37

And again, if the answer is yes, then

1:39

that would meet the definition of an error.

1:41

Now, when it comes to the communication of these issues,

1:44

though, it's sometimes a false dichotomy to try to divide

1:49

between what's an, uh, preventable

1:51

and unpreventable adverse event,

1:53

because both sorts of events can lead to very

1:58

delicate, sensitive and difficult communication requirements

2:02

and, uh, uh, and skillfulness as needed re regardless

2:06

of whether it's preventable or unpreventable.

2:10

So at general guidelines of when to

2:16

communicate about these sorts of events, uh, the can be, uh,

2:20

can be given as, would you want

2:23

to know about the adverse event or, uh, or the,

2:26

or if it happened to you

2:27

or a family member, you could ask it in another way.

2:32

Would a reasonable person want to know?

2:35

Or you could ask it in another way, which is,

2:38

if you weren't told about the event

2:41

and you it, the event came to light to you

2:45

sometime down the line through another avenue,

2:48

how would you feel about that if you would be upset about it

2:52

or if a reasonable person would be upset about it?

2:55

That's an important threshold to think about.

2:57

Another important threshold

2:58

To think about is could the event

3:00

or error result in a change in the patient's treatment,

3:03

either now or in the future?

3:04

Now you can think about this very narrowly

3:06

and say, well, the diagnosis of the diagnosis

3:09

and the treatment isn't gonna change.

3:10

But broadly speaking, if a patient could reasonably say,

3:14

I don't want my care in this institution anymore,

3:17

or I don't want this radiologist to be involved in my care,

3:20

then that is also a important threshold to consider.

3:24

The rationale for why we bring these communications

3:28

to patients and families, uh,

3:30

has been fairly well established.

3:32

First, it is in keeping with the standards

3:34

of informed consent

3:35

and patient-centered care, uh, to provide patients

3:39

and families with the information that they need, uh,

3:42

when they need it to make decisions according

3:45

to their values and preferences.

3:47

We know that errors

3:48

and events can undermine the trust that patients

3:51

and families have in their providers

3:53

and in their medical systems.

3:54

And it's felt that bringing forward the communication in a

3:57

trans in a transparent way with accountability re helps

4:02

to reestablish the trust that is so important

4:05

to the therapeutic relationship.

4:07

We know that patients

4:08

and families often experience significant

4:11

long-term emotional

4:12

and psychological distress in the setting

4:15

of harmful events and errors.

4:17

This can lead them to, uh, to, uh,

4:21

delay medical care down the line

4:23

that may be very important for their health.

4:25

And it's felt that good healthy communication about these

4:28

events can help mitigate those emotional harms

4:31

to patients and families.

4:34

The communication is felt to be important for QI purposes.

4:37

That is institutions that take accountability

4:40

and transparency with patients

4:42

and families around these events tend

4:44

to be those institutions that have healthier communication

4:47

internally and more robust abilities

4:52

to put together processes down the line

4:54

to mitigate the likelihood of such events in the future.

4:57

And finally, we know

4:58

that these events are very hard on the practitioners

5:02

who may share in the responsibility, the nurses,

5:05

the physicians, and others.

5:07

And it is felt that giving the providers the opportunity

5:12

to talk to the patients

5:13

and families about these events, uh, can help

5:17

to reduce the burnout, the anxiety, the depression

5:21

that often accompanies the, the, the providers, uh,

5:24

when they, these events occur.