- Senior risk management consultant for the Mutual Insurance Company of Arizona.
- Healthcare career includes clinical nursing (7 years in PACU), professional liability claim management and risk management.
You'll never be able to eliminate all adverse outcomes in surgical facilities, but you can learn a lot from the painful experiences of others. Case histories and claim-loss data show clearly how you can dramatically reduce the number of adverse events, and how practicing risk-management strategies can help you defend yourself when they occur. Karen Wright, RN, BSN, ARM, CPHRM, senior risk management consultant at Mutual Insurance Company of Arizona, brings 40 years of experience to her invaluable presentation "When Bad Things Happen in Good ORs: Case Studies in OR Liability." We spoke to Ms. Wright about the importance of risk management and learning from others' mistakes.
- More than meets the eye. When I had the opportunity to change my career path to hospital risk management, I was thrilled. I thought I'd finally learn how to prevent the errors that harm patients and create lifelong nightmares for caregivers. Unfortunately, the picture wasn't as black and white as I had presumed. Instead, there were multiple shades of gray.
- Layers of vulnerabilities. As I worked with hospital employees and physicians to resolve claims and lawsuits, it became apparent that medical errors could rarely be attributed to a single person. Instead, there was usually a convergence of multiple process or system failures that ultimately culminated in the error. Reviewing closed claims and lawsuits created an opportunity to peel back the layers and identify the vulnerabilities that contribute to adverse outcomes.
- Common causes of errors. Despite improved technology with monitoring equipment, many adverse patient outcomes can be traced back to inadequate or absent monitoring of patients during the intra- and post-operative periods. Often these errors are related to human factors, such as distractions, alarm fatigue and even user error. Failure to provide clear instructions and advice to patients and their families are other common allegations, especially in the post-operative timeframe. This often goes hand-in-hand with failure to recognize a complication. There can be a significant delay in care if patients and families do not clearly understand what complications they should watch for and what steps to take when they occur.
- Standing your ground. Not every adverse outcome is the result of a medical error. Lawsuits and claims may arise when patients experience a complication or unexpected outcome in the absence of any medical negligence. In these situations, you must be in a position to vigorously defend any allegations of negligence. Closed claim and loss analysis can pinpoint causal factors that have contributed to adverse outcomes and identify practical risk-reduction strategies. The cost of medical errors is always too high. But we can look at the experiences of others, identify what went wrong that could have been prevented, and focus our resources on learning from those failures.