Disclosure of Adverse Events: A Guide for Clinicians

Kimberly A Peterson; Mary Rutherford; Denise Drvol; Darlene Barkman; Amber R Phipps; Roberta Hales; Aaron Dawson; Laurie Stevens; Susan Teman; Jeanette Teets

doi:10.1097/pq9.0000000000000185

Disclosure of Adverse Events: A Guide for Clinicians

Pediatr Qual Saf. 2019 Jun 27;4(4):e185. doi: 10.1097/pq9.0000000000000185. eCollection 2019 Jul-Aug.

Authors

Kimberly A Peterson¹, Mary Rutherford², Denise Drvol¹, Darlene Barkman³, Amber R Phipps¹, Roberta Hales³, Aaron Dawson⁴, Laurie Stevens^{1

2

3

4

5}, Susan Teman⁵, Jeanette Teets³

Affiliations

¹ Children's Hospital & Medical Center, Omaha, NE.
² UCSF Benioff Children's Hospital Oakland, Oakland, CA.
³ Children's Hospital of Philadelphia, Philadelphia, PA.
⁴ Children's Hospitals' Solutions for Patient Safety Network.
⁵ Spectrum Health.

Abstract

Introduction: Children's Hospitals' Solutions for Patient Safety (SPS) acknowledged a recommendation from the American Academy of Pediatrics to develop education programs on the communication of adverse events with patients and families. SPS set out to create a guide that would outline a standardized disclosure process and provide a training curriculum and tools so that providers would feel better prepared to have effective disclosure conversations.

Methods: SPS disclosure work began with the development of a project team made up of 9 network hospitals. The team utilized key driver diagrams and process maps to show the relationship between the project aims, key drivers, and specific interventions. The team developed a training curriculum, guide, and tools for each area of improvement. To ensure these were effective, they were tested using case studies and plan-do-study-act cycles.

Results: One of the cohort hospitals piloted the curriculum and tools, training 48 physicians, nurses, executives, and other allied health professionals. Pretest to posttest scores improved from an average of 82.7% to 90.2%. Survey feedback was favorable with 100% of respondents noting that they strongly agree or agree that attending this educational activity increased or improved their competency, performance, and patient outcomes.

Conclusions: Initial testing suggests that the developed curriculum is empowering for frontline clinicians. Materials are available in an electronic format on the SPS external website. As member hospitals implement these materials, they will be evaluating learner satisfaction and provider usage. SPS will seek out feedback from these hospitals to further develop the materials and support clinicians.