Mistakes that burn

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Medical administration is a rewarding profession, but it comes with challenges. So what is it like and what should you do if confronted with a monumental administrative difficulty? This is the podcast that takes unfortunate scenarios and explores the essentials of clinical governance to find solutions. I'm Dr. David Rankin. A very experienced medical administrator and lead fellow with the Royal Australasian College of Medical Administrators. And this is Safeguarding. The essentials of clearing.

Today, mistakes that burn. This is really most unfortunate and really raises many concerns. That's Professor Mary O'Reilly. The Chief Medical Officer at Austin Health in Melbourne and I'm presenting her with a difficult scenario. The fact that there's been no communication really does contribute to why the patient is angry. In today's scenario, you receive a complaint from a very angry patient who has been left.

Burn that is turning into a large scar on their shoulder following plastic surgery to remove a skin cancer on their face. Your initial investigation indicates that the lead to the headlamp that the surgeon used was clipped to the drapes across the patient's shoulder area. The connection to the lead had not been fully inserted, likely heating up during the lengthy procedure.

The headlamp belongs to the surgeon, and they connected the lamp up and checked that it was working. At the end of the case, the theatre staff noticed a hole in the drape and made an entry in Risk Man. The surgeon briefly examined the burn and said it would heal up fine. Nothing appears to have been communicated to the patient about the burn or its likely cause.

The patient is now threatening legal action and wants the hospital punished and the surgeon struck off for what they believe was an eminently preventable injury.

I started by asking Professor O'Reilly what overall concerns an incident like this raises. I think first and foremost is actually the patient who's at the center of this. The patient was likely to be concerned and distressed before this happened because they were having a skin cancer taken off. And so this is going to be an additional concern for them. The fact that they are so angry suggests to me it's possibly a younger patient.

and that um it's likely to be an area that's visible from the information that we have and the fact that it's scarring i is really problematic. The facial lesion is potentially uh quite problematic because they need an operating theater and general anesthetic. So the fact that it wasn't taken off in in the rooms uh tells you it's likely to be more serious.

And the burn is painful and scarring. This is again, you know, really serious. And the fact that there's been no communication really does contribute to why the patient is angry. In my experience, when we communicate well Often patients are really understanding but when we don't communicate then that tends to give this sort of problem.

There's also likely to be some additional costs and obviously care required for the burn. I think the second issue really is all our systems. So firstly the equipment. So I note that it's the surgeon's equipment but you know, was it maintained? Had it had its electrical checks? And the operating theatre processes in terms of checking as we go and having uh something that uh was under the drapes that no one could see that's a risk is actually again a significant problem.

I'd worry also about, you know, has this happened before? In general when things happen it's not the first time. And very seriously we would be using inflammable gases in an operating room and oxygen so that this is potentially a near miss for a very, very serious event. There's also the concern about how the incident's been managed, managing not only the patient, the surgeon, the staff, the fact we didn't have any open disclosure, like a follow up.

And also it raises broader issues in terms of the culture of the organisation and the operating theatre and obviously considerable legal issues as well.

I agree, an awful lot of issues here. Let's start off with what's your initial response to this complaint? So all organisations have a process and it's really important that you follow your organizational process. But the basic principles are that you need to respond very quickly. This is the sort of complaint that I think should have a follow up phone call to the patient to acknowledge not just the standard email that often will be sent out.

and it needs a phone call to apologize. Now, acknowledging that we don't have the information and we do need to investigate that, but this uh I think we still should ring and apologise. We need to check in how they're going at the moment and their current care. Is there anything that we can assist with that? care of the burn and also they may not have come back for follow up care of their facial skin cancer because if they're very angry then they may not have had follow up for that either.

I would uh let them know that we'll need to look into this and that we will get back to them and give them a time frame. And then I would actually confirm that conversation in writing. Given that they've threatened legal action, who do you think the most appropriate person to pick up the phone and talk to them might be? Again it depends on your organisation, but the feedback that we have is in general the best person to pick up the phone is going to be a clinician.

not the lawyers. If we get our lawyers to ring them then they feel that we're trying to be defensive and what they often want to do is to hear from a clinician Or and again it depends, it may be your quality team, it may be your complaints or feedback team, but somebody who's experienced and who can actually answer their questions. And I wouldn't use my lawyers. We always let them know when we have an issue like this and we would tell them after we had some initial information.

So for me where I work, which is a large public health service. then that would be our quality team initially picking up the phone, who are very experienced at dealing with people providing predominantly unfortunately negative feedback. I think it's a really hard call on who is most appropriate to call somebody like this. They're very angry.

I guess my call is that as DMS I may call them myself because I've got a medical background and may be able to explain some of the things and understand the implications. I think it's a hard call to work out who's the best to call the patient. I think it does depend on your organization and part of that depends also on your role in the organization. So I think that it's more likely perhaps if you're in the private sector that the DMS might make the phone call.

And perhaps if you're in a smaller centre. But I I think you're right, it can be difficult and uh you need to work out what's going to be best for the patient and what's best in your organisation.

So we already know what caused the burn and the apparent heating up of the junction in the cable. What other information do you want to discover in an investigation of an incident like this? It's really important to understand as much as possible. So I think one of the things at this point is not only in relation to this patient, but making sure that it can't happen again.

Who might be an operating list on today with this headlamp or someone else using a similar headlamp in use So I'd really want to sort that out very quickly. Interested to know whether it's our headlamp or the surgeons. It's very commonly actually is the surgeons rather than the hospitals.

whether there was a problem with the headlamp at all, had it happened before and often in my organisation we'd run a safety huddle. We'd try and sort out what had happened and try and make sure it wasn't going to happen again. before we go to the more detailed investigation of this particular case. You have a pretty good idea of what happened. How much information are you going to share with the patient at that initial contact?

Often when we have an initial contact we actually don't have much information. So we'd have the fact that the patient had a burn that they acquired in theatre with us, but I wouldn't have known it was the headlamp. so that we would have to be investigating and telling them that we will have to look into this and find out what's happened. And then we'd get back to them fairly quickly, as in a day or two, depending on what we found.

Now it is difficult working out what to say. In my jurisdiction we actually do have uh legislative protection in terms of open disclosure to patients. so that we would actually be letting the patient know and in fact subsequently when we'd finalised our investigation we'd give them a written response. Now, it's very different in some other jurisdictions and it can also be different in private, whereby one can have challenges with one's own lawyers and also your insurers.

who may advise that if you admit liability then they're not indemnifying you and you're effectively self insured. So it is a matter of navigating that and we navigate it with our legal team, who navigate it with our insurers. And in this case likely there'll be a medical defence organisation involved as well.

so that we navigate that. The MDOs now are actually generally very supportive of open disclosure. Again, In fact the outcomes are better for the patient but also for the insurers if you're open about what's happened.

One of the challenges with a scenario like this. is that the surgeon may be as equally at fault as the hospital. It was the surgeon's headlamp, they brought it in, they plugged it in, they were effectively responsible for looking after it. How do you communicate the contribution of the surgeon versus the contribution of the hospital when talking to the patient?

I think that's a really important question and the principle that I work on is a no blame. I it's a really no help to the patient to say, well, it wasn't anything to do with us at all related to your surgeon. And it is related to us as well, because we let the surgeon bring their headlamp in. We are the ones responsible for the processes to ensure that the patient's safe.

So it is actually shared. So I think that I would completely avoid blaming in this case a surgeon, but blaming anyone. Neither would I be blaming the theatre staff. I think working on a no blame culture is really important. It's important for the patient, for the surgeon, the staff and the organizational culture. If you want people to tell you things and report things, you've got to have a no blame culture.

So we would apologize saying that we're really sorry this has happened, but we wouldn't be blaming the surgeon. In terms of apportioning liability, that's something that the insurers do in the back end. But I wouldn't involve the patient in that. Is it different in private where the surgeon is a VMO and an independent practitioner versus in public where they'd be a salaried employee? So if this is public patient then the doctor and the organisation are all being covered by the same insurer.

If it's private the doctor is being indemnified by their own medical indemnity organisation and the hospital's being indemnified by their insurer. One of the problems is that sometimes it's difficult to engage our clinicians when something's gone wrong. And that's something that I would definitely be involved with. I think it really needs a very senior medical administrator to be involved in uh navigating that with our surgeon.

Tell us about how that process works. How how do you engage the surgeon? When do you engage with them? And when do you raise the potential for joint settlement? I'd engage with them as soon as I knew about this. So we'd work out where they were, whether they're operating with us, whether they're in rooms, clinics, wherever, and then gives them a call, you know, at the end of a session or something like that and ask them to

Come and have a chat with me. Sometimes they can't do that, they're at a distance and sometimes we do have to discuss it over the phone, but I make sure it's an appropriate time. Initially it's about letting them know that we've had this complaint. And then trying to get some more information and sitting down working out what has happened.

We would often involve them in our safety huddle if we could, but that again may not be possible when people work in different areas or part time across different locations. I'd also follow up and I would actually let them know that they are likely to get an notification to APRA or dependency jurisdiction. potentially the uh office of the health ombudsman because the patient's very angry. And nowadays it's very easy to notify. If you go to the APRA website, it's on the front page.

Click here. And we know that this is what a lot of our patients are doing now. Annually there's an increase in notifications. It's around about six percent of all health medical practitioners. and notified annually at the moment. So I think it's also supporting them as well because in general clinicians get very stressed and anxious when they get a complaint. We need to support them through that.

However, we also need to navigate the way we need to manage this, which is being open and transparent with the patients. Coming back to the patient, how much responsibility do you take for their remedial care? Would you pay their costs to see a different plastic surgeon about potential treatment for what's turning into a keloid? Yeah, good question. And I think this is something that does differ in public and private. So in public what we do is offer

to follow them up in general with a different surgeon, making sure it was a senior surgeon. Sometimes they won't come back to us, in which case we would facilitate care at another public hospital. In general in public we don't facilitate private care. Now in private it's a different situation and given the risk that it is the sort of situation where it is probably likely to be not only good for the patient but also better for the organisation.

to offer to facilitate and fund consultation with another plastic surgeon and to contribute to the cost and including some ongoing care. which could actually be quite significant if this patient develops keloid. Yeah. I guess one of the things in responding to a complaint like this is to be able to put those sort of things in place as quickly as you can. So that the patient, the complainant, realizes that the hospital is serious and is prepared to assist as much as they can.

This case provides a number of learning opportunities, I guess. It was um a mechanical failure. How much of the complaint process do you share with theatre staff to help them learn? Also with medical staff sharing it at the perhaps the plastic surgery M and M meeting as a case that's worth reflecting on. So how much information can you give to staff on the basis that this is an opportunity for learning?

I think that's a really good question and a really good point. And we know that if we don't share information that things are more likely to happen again and also that we won't hear when there are problems. So that we would actually share this, for example, a team meeting in theatre. Now it'd be de identified. Some of the theatre staff will already know because they will have been interviewed as part of the incident review. Once we'd worked out this was the problem.

we would have put some controls in to stop it happening again and that would have been communicated with all the theatre staff. So not the information or the detailed information about a patient, but we would tell them that a patient had been burnt. and that now moving forward this is what is going to happen at timeout and various other

points uh and working with them because they'll know how to deal with things. So we would actually have involved them and also it helps support the safety culture and also the escalation of, you know, when they notice something that's a risk. to let the relevant management team within theatre know so that we can actually address it.

I would have expected that this should have been presented at the surgical M and M meeting. So I think there's a variety of systems things that we would have implemented and it's really important that they are shared and that they also should be shared across the sector.

But there's also lessons learnt from the safety bodies, which for me is safe at Care Victoria. So they also send out lessons learnt across the sector and I think that's really important because whenever you hear about these things You need to think, could this happen with us and use these as a learning opportunity more broadly. اشتركوا في القناة

It can be quite threatening to the surgeon to have their case used as a case study. Does the surgeon have the power of veto to say no, I don't want you to share this case with others? No, they don't. However, I think the way to work around that is we work with them and often at the end of the day they will present it. So by owning it, that's actually much better than having the organisation present it.

So and some it just takes a little time and that's fine you've got time because you've already implemented your safety changes. The surgeons will usually own it, in my experience. It's also around supporting them in the early phases when they first know about this and ongoing. So if you sit down with them and talk with them and also do welfare checks and have the no blame culture, this is not about blaming them.

this is a shared problem, we need to fix it together, then they're more likely to be happy to share it. But in my experience people will in general share. They may initially not want to, but Again, we don't tend to ask, you know, in the first or the second conversation. It's a much later conversation about it's it'd be good to present at your unit meeting or the divisional meeting wherever's appropriate. I think that's a really key point. Communication

particularly with the surgeon, is so critical. Letting them know what the process is going to be, what how the investigation's going to go, what conversations you're going to have with the complainant. um supporting them through any APRA concerns that might be raised. But also making sure they're aware of your intention to perhaps use this as a case study for learning so that they know beforehand and don't get surprised.

Mary, any final thoughts on this quite challenging case? Yes, it's very challenging, David. And I think it reflects a lot of the complexities in health. This sort of thing is really difficult for the patient but also very difficult for all the staff. And you have to remember the nursing team as well. They are secondary victims with this and we have to make sure we support them. We also have to consider how we support the surgeon and the staff through

And that there's a variety of supports available. All organisations have employee assistance. Many doctors will not use that, but I do actually talk with them about it. The medical defence organizations also have AAP and there's various other doctors' helplines as well, apart from the organization But I often find that, you know, being available, able to have that kappa, they can call you and often they worry more as time goes on. So it's being available and during the check in.

getting back to the patient, it's also we've got to go back to the patient and let them know And follow up on them as well to make sure that they are getting the care they need and to tell them what we've done to stop this happening again. That was Professor Mary O'Reilly. Chief Medical Officer at Austin Health. And that brings us to the end of this episode of Safeguarding Homes. Amen. to David Rainkin.

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