Andrew Kohner Mauricio Gonzalez 18
Adverse Event Documentation: Goals, Thoroughness, and Mistakes to Avoid
Debriefing after Critical Events Crisis situations can have significant emotional and psychological impact on both participants and bystanders, often leading to traumatic stress. Therefore, it is crucial to conduct debriefing sessions after critical events, ideally within 24-72 hours of the event. These sessions should be facilitated by trained individuals who can create a safe and supportive environment for discussion. For a more detailed exploration of debriefing, please refer to Chapter 22. Conclusion The principles of effective communication that apply to the workplace are equally relevant in crisis situations. Regardless of the urgency and severity of the circumstances, the use of effective nonverbal cues and verbal communication strategies remains vital. Healthcare providers can acquire and refine these crisis resource management skills through training, learning, and practice in a non-threatening, interprofessional environment like a simulation center. By recognizing the importance of communication during crises, healthcare professionals can enhance their ability to navigate and resolve critical situations. Incorporating crisis resource management training into education and professional development programs enables providers to develop effective communication techniques, make timely decisions, and collaborate as a cohesive team when confronted with high-stakes scenarios. This, in turn, leads to improved patient outcomes and a safer healthcare environment. By prioritizing effective communication in both routine and crisis settings, healthcare professionals can create a culture of clear and efficient information exchange. This culture fosters teamwork, reduces errors, and enhances overall patient care. It is essential for healthcare organizations to invest in communication training and provide opportunities for healthcare providers to practice and hone their communication skills, ensuring they are well- prepared to handle crises and deliver optimal care to patients.
Learning Objectives 1. Understand the goals of charting and documenting an adverse event. 2. Describe what constitutes a thorough documentation of adverse events in the medical record. 3. Identify common mistakes to avoid when documenting adverse events.
Suggested Reading 1 Davis, W. A., Jones, S., Crowell- Kuhnberg, A. M., O’Keeffe, D., Boyle, K. M., Klainer, S. B., et al. (2017). Operative team communication during simulated emergencies: Too busy to respond? Surgery, 161(5), 1348–1356. DOI: 10.1016/j.surg.2016.09.027 2 Foraida, M. I., DeVita, M. A., Braithwaite, R. S., Stuart, S. A., Brooks, M. M., Simmons, R. L., et al. (2003). Improving the utilization of medical crisis teams (Condition C) at an urban tertiary care hospital. Journal of Critical Care, 18(2), 87– 94. DOI: 10.1053/jcrc.2003.50002 3 Fung, L., Boet, S., Bould, M. D., Qosa, H., Perrier, L., Tricco, A., et al. (2015). Impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: A systematic review. Journal of Interprofessional Care, 29(5), 433–444. DOI: 10.3109/13561820.2015.1017555 4 Gaba, D. M., Howard, S. K., Fish, K. J., Smith, B. E., & Sowb, Y. A. (2001). Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simulation in Healthcare, 32(2), 175–193. doi:10.1177/104687810103200206 5 Patterson, K., Grenny, J., McMillan, R., Switzler, A., & Gregory, E. (2002). Crucial Conversations: Tools for Talking When Stakes Are High. McGraw Hill.
Introduction Adverse events (AEs) in healthcare can have serious consequences for patients, ranging from prolonged hospital stays to permanent harm, life-saving interventions, or even death. Reports suggest that up to 25% of patients experience AEs, and approximately half of these incidents could be prevented. Accurate and timely documentation of AEs in the medical record is of utmost importance, regardless of whether it is electronic or paper-based. This chapter provides valuable guidance on documenting unanticipated events and outcomes during patient care. The objectives of documenting an AE include ensuring the availability of medically relevant information, facilitating learning from the incident, and creating an accurate record for potential legal or regulatory actions. By adhering to documentation guidelines such as prompt recording, objective description, avoidance of speculation or derogatory comments, and comprehensive reporting of interventions and interactions, healthcare professionals can ensure comprehensive and accurate documentation of AEs, support ongoing patient care, and prepare for potential legal or regulatory proceedings.
Rationale Accurate and comprehensive documentation in the medical record is crucial as it serves as a legal document and ensures the continuity of patient care. Now that patients have immediate and cost-free access to their electronic health records, healthcare professionals and systems have a responsibility to promote documentation that is factual, concise, understandable, and supportive. When documenting an AE, there are three primary objectives: 1. Ensuring Availability of Medically Relevant Information: The documentation should contain all pertinent details necessary for the ongoing treatment of the patient, enabling healthcare providers to have a complete understanding of the event and its implications for the patient’s care. 2. Facilitating Learning from AEs: Documentation should provide information that allows healthcare professionals and institutions to analyze the AE, identify contributing factors, and implement measures to prevent similar incidents in the future.
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