“The mindset at that time was that bad things happen, but you move on. You just don’t get emotionally engaged,” says van Pelt. “I was back doing regional anesthesia the very next day.”
Now, van Pelt feels like he is more in touch with his own humanity as well as that of his patients. “If you use integrity and compassion as your drivers,” he says, “the outcomes can be amazing.”
Support from institutions
James Conway, a self-described supporter of MITSS, says that Boston’s Dana-Farber Cancer Institute, where he is executive VP/chief operating officer, learned from Massachusetts’ Betsy Lehman case 10 years ago, in which the patient received overdoses of chemotherapy and died. Conway and others at Dana-Farber have recognized that there are multiple victims following a traumatic event. “There’s clearly the patient and the patient’s family and friends,” says Conway, “but there’s also the staff members who came to work that day intending to deliver exceptional care and instead find themselves at the ‘sharp end of the error.’”
Dana-Farber also learned that when these events happen, they must be fair and just and not punitive. “The event does not assume one person is responsible when there’s a systemwide responsibility,” he adds.
The message from van Pelt and Kenney resonated with the message Dana-Farber wished to deliver. The hospital has offered financial and logistical resources to MITSS for several reasons, says Conway. “First, they’re good people. Second, they brought an important message that reinforced Dana-Farber’s position on support after adverse events. And last, their vision would bring a degree of depth which was more than the depth we have.”
Dana-Farber’s No.1 responsibility is to the patient, says Conway. The institute offer staff support through an employee assistance program, as well as private counseling. Staff are always included in the evaluation of the event because, Conway says, “we want the discussion to be about what happened, not who’s to blame.” Dana-Farber uses MITSS as a resource on how to view an event and advise on processes.
And Dana-Farber makes sure that staff knows about MITSS. Kenney’s message from MITSS “is not just about incident and harm,” says Conway. “She and Rick [van Pelt] are able to talk about partnerships and the role of family-centered care.”
MITSS and the patient
safety movement
The patient safety movement has traditionally focused on prevention of error —standardizing care and eliminating human error as much as possible. “The patient safety movement has not yet focused on taking care of the people involved in adverse medical events,” says van Pelt, “and MITSS completes the loop.”
MITSS is putting together a model for patients and families who experience a medically induced trauma, according to Kenney. The organization is using the experience of several of its support groups to develop the model. When the model is in place, Kenney says that Kaiser-Permanente in California plans to use it in addition to the strong clinician support program already in place.
Conway recognizes that other hospitals might not accept the MITSS vision. First, there is a major issue of confidentiality. “Health care still doesn’t have really good systems to safeguard care and information,” says Conway. Other hospitals may wonder if they can successfully link MITSS with their current support programs. Finally, the concept of the “the other victim of error” [the clinician or staff member] is new territory and has been talked about only in the last five years.
Kenney recently attended the National Academy of Science’s meeting about patient error and says that great things are happening in the patient safety movement. “But it will take years to improve systems to where there is very little or no error,” she says. “In the meantime, patients and clinicians will continue to have emotional backlash.” And helping them all through the trauma will be MITSS.
Karla A. Knight, RN, MSN, is a frequent contributor to Nursing Spectrum.
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