Ditching the shame and blame

A decade ago, Dr. Brian Goldman stood on a stage in Toronto and asked: Why don’t physicians talk about their mistakes? “Here’s the problem: If I can’t come clean and talk about my mistakes, if I can’t find the still small voice that tells me what really happened, how can I share it with my colleagues? How can I teach them about what I did so they don’t do the same thing?” he asked as part of his TED Talk, now viewed more than two million times. Dr. Goldman is an emergency physician in Toronto and host of CBC Radio’s White Coat, Black Art. “That’s the system that we have: It’s a complete denial of mistakes.” Whether that was the situation 10 years ago, it’s certainly not the case now. Every hospital has always had a process for reviewing critical incidents of patient harm, but the tenor of the discussion has changed. Physicians no longer have to don a dunce cap—or a sign reading “bad doctor”—and sit in the corner, shunned. Instead of denying mistakes, there are layers upon layers of processes designed to lean into critical incidents, examine them and learn. Even the term mistake is frowned upon, because if there is patient harm in a hospital, it is often due to a systemsrelated problem, not an individual’s error. “It is usually as a result of multiple, multiple actions or inactions,” explained Dr. Lucas Chartier, an emergency physician and medical director of quality and safety at the University Health Network (UHN) in Toronto. PROTECTING MEANINGFUL CONVERSATIONS Legislation has helped shift the culture from finger-pointing to quality improvement. Since Dr. Goldman’s TED Talk, Canadian provinces and territories have made progress in mandating elements of critical incident reviews in hospitals, such as what must be reported and what must be disclosed. Legislation also allows physicians to apologize and share information without fear of it being used in legal proceedings. Dr. Chartier said a piece of Ontario legislation, called the Quality of Care Information Protection Act (QCIPA), plays a role in helping healthcare professionals feel safe when discussing critical incidents. It ensures that information shared during critical incident reviews can’t be used in legal proceedings. UHN invokes QCIPA in all critical incident reviews. “The fact that it is protected under the auspices QCIPA allows providers to feel safe—and that’s the whole point of QCIPA, to be able to engage in these meaningful discussions in a way where they don’t feel repercussions, whether it is medical, legal or employment-based,” Dr. Chartier said. Otherwise, healthcare professionals wouldn’t participate and it would nullify the benefit they could potentially glean from the reviews. In April 2021, Healthcare Excellence reviewed patient safety legislation across Canadian provinces and territories. “That legislation has commonalities but is not exactly the same everywhere,” explained Jennifer Zelmer, president and CEO of Healthcare Excellence, a body formed a year ago to bring the Canadian Patient Safety Institute and Canadian Foundation for Healthcare Improvement together under one roof. Read: Patients without doctors—coast to coast Quality assurance legislation like QCIPA, that prevents information from critical incident reviews from being used in legal proceedings, is in place in all Canadian jurisdictions, but Healthcare Excellence noted several areas where it can be improved. It called for more clarification on what information revealed in the critical incident review process is protected and what is not. Harmonizing these laws across the country would benefit patients by bringing clarity and consistency to the critical incident review process. For example, while quality assurance legislation still allows findings from critical incident reviews to be disclosed to affected patients and their families, there’s the tricky issue of how far transparency goes. In a publicly funded healthcare system, the public is understandably invested in patient safety incidents, but how far the information flows must be well-defined in legislation to protect patients and providers alike. Another piece of legislation that allows physicians to speak freely focuses on apologies. In 12 out of 13 jurisdictions in Canada, the legislation is the same: an apology is not an admission of fault or liability. This means healthcare professionals can express sympathy without it being taken legally as an admission of culpability. The thinking is that this not only improves communication, but leads to quicker resolutions, Healthcare Excellence notes in their report. Only the Yukon has no legislation protecting apologies. EFFECTIVE CRITICAL INCIDENT REVIEWS Despite laws regulating certain aspects of critical incident reviews, how the reviews are carried out often differs from hospital to hospital. For example, in Saskatchewan, the amalgamation of 12 former health regions has meant there’s a lot of variation on how critical incident reviews are conducted. It’s something the Saskatchewan Health Authority (SHA) is actively working to change. “We recognize the opportunity to standardize processes provincially and this is our focus over the next one to two years,” the SHA told the Medical Post. Hospitals and health authorities can look to the Canadian Incident Analysis Framework, which outlines best practices on understanding what happened, how it happened, why it happened, and what can be done to reduce the risk of recurrence to make care safer. The World Health Organization also has guidelines on how to conduct a review. Yet there is no one set way to analyze an incident: the Canadian framework includes multiple methods to use when conducting a critical incident analysis. The outcome of the incident is only one factor that decides what method is used, explained a spokesperson for Alberta Health Services (AHS). Read: The book of awesome: A few of our favourite things “The general process for reviewing events has not changed fundamentally, although, recently it has been recognized that alternative review methodologies or processes other than the traditional approaches could support quality improvement and learning as they take more of a non-linear and systems-based view,” she said. The focus is on making sure everyone feels safe in discussing quality and safety issues. ncidents land on several desks, including the staff involved in the incident and the health quality and safety team. A review happens quickly with team members—when memory of the incident is fresh—and then the case may go on to a more formal analysis. “There are multiple layers depending on the specifics of the case,” Dr. Chartier said. “There will be an interprofessional discussion and then we will determine the root causes of the issues and if there are opportunities for recommendations for the hospital, for the providers, for the system: we try to be as fulsome as possible.” Including as many perspectives as possible also helps capture the best understanding of the event, the AHS spokesperson reported. This includes hearing the patient’s point of view. “There has been a fair bit of learning in that set of processes,” Zelmer said. “There’s also typically more involvement of patients and families now, in the vein of ‘nothing about us without us.”’ It’s important to note that the critical incident review process is not used to evaluate an individual’s performance, the AHS spokesperson noted. The World Health Organization’s (WHO) guidelines note that successful reviews must shine the spotlight on systems and processes rather than on individual performances. Improvement of patient safety cannot exist if there’s fear and blame, Zelmer explained. “It is being able to understand what does a safe and just culture look like, that marries learning and accountability and engagement all together.” Learning should always be the outcome of a critical incident review. In that light, near-misses or “good catches” could also be analyzed. In 2009, the WHO suggested that near-misses in maternal death should be scrutinized for learning opportunities as well as true incidents of maternal death. This can lead to a better understanding of what contributes to actual or potential harm, and can inform changes to improve patient safety. Like diagnosis without treatment, analyzing a critical incident alone does not result in patient safety. It’s only when hospitals adopt recommendations that better outcomes can occur. Some could be very floor- or clinicspecific recommendations of a systems change, while others may affect the larger healthcare system. Healthcare Excellence works with many partner groups to help spread the word on best practices for patient safety. Zelmer notes that patient safety starts with good design, not luck. IMPROVING THE PROCESS The work to improve the critical incident review process is ongoing. The SHA just completed guidance for clinical leaders on post-critical incident analysis disclosure, helping them with follow-up conversations with patients and family. SHA has also revised three provincial policies about critical incident reporting, disclosure and responses set to go out for broader consultation. The UHN is currently working on how to incorporate non-physical harm into their model of patient safety. “We have a renewed focus that there are significant other emotional, psychological harms—community harm as well, with patients who go back to their community and may have had trauma as a result of their experiences,” Dr. Chartier said. “How can we best capture this in a way that will be fulsome and wholesome to the patient experience and allow us to improve not only the medical care that we provide, but on all of the other aspects that have an impact on patients?” There’s also a renewed push to help those involved in the incident. A critical incident or a near-miss weighs heavy on healthcare professionals, as Dr. Goldman recounted in his TED Talk. Zelmer said this toll on healthcare workers is being recognized. “There’s an emerging focus on healing after harm, not just what happened at the time, but how can we look forward in terms of healing for all of the individuals who might have been involved in the incident." The changes in the critical incident review process have perhaps increased the number of incidents or near-misses reported at the UHN, Dr. Chartier said. Whereas five to 10 years ago, these scenarios may have gone unreported, “I think now we have a culture of safe reporting where people believe that the over-reporting of events is something that is going to lead to better care for all,” he said. Read: The pain of paperwork comes in many forms

Ditching the shame and blame

Register for free access or login.

Related Topics