OPSC Patient Safety Minute | Communication Between Facilities When Harm Occurs

When it comes to communication between facilities around harm events that impact shared patients, there’s a gap in published recommendations. As part of Oregon’s first Patient Safety Survey, we asked facilities how they communicate with other healthcare facilities about harm events that involve shared patients. Here’s what we learned!

What We Learned from Oregon Facilities

One of the benefits of our healthcare system is that it operates on a continuum, where patients can receive different levels of care based on their needs. For example, a patient may have surgery at a hospital and be transferred to a rehabilitation facility to support their recovery. We were curious about how facilities communicate with each other when harm occurs in the care of a shared patient. As part of our Patient Safety Survey, we offered respondents two scenarios:

1. A patient experiences harm from the care they receive at another facility and then seeks care at your facility; or

2. A patient experiences harm from the care they receive at your facility and then seeks care at another facility.

Only 6% of survey respondents said they don’t have a policy or procedure in place for communication about harm events that occur at another facility (or they are unsure if they have a policy). Despite the above scenarios only being applicable to about half of respondents, nearly all respondents reported knowing how they would handle a similar situation.

Most respondents shared that they do, or would, use direct communication with another facility when a harm event occurs. When asked how this communication occurs, the most common response from all facility types was that it occurs “between clinicians” (82% of all responding facilities). The second most common response varied depending on the type of facility. For nursing facilities, the second most common response was “between senior clinical leaders,” for hospitals it was “between other facility staff,” and for ambulatory surgery centers, it was “electronic medical record.”

Suggestions from the Experts

When it comes to communication between facilities around harm events that impact shared patients, there’s a gap in published recommendations. To try to fill that gap, we reached out to the experts at the Center for Harm Response and the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) to get their recommendations for what facilities should be thinking about. They made the following suggestions:

For Facilities in the Same Healthcare System

• Work together with the other facility on the event review and analysis

• Identify a single point of contact for the patient and family

• Participate in conversations together with the patient and family

For Facilities in Different Healthcare Systems

• Coordinate and communicate with the other facility through your risk or quality departments

• Let the other facility know that you’re working on an event review and analysis and are planning to share the results with the patient and family (encourage the facility to do the same)

• Invite the other facility to the conversation with the patient and family

Did you know that you can use the Patient Safety Reporting Program (PSRP) to support your coordinated event review? Our statute provides confidentiality for facilities that participate in PSRP to communicate about an adverse event as long as they intend to share what they learn with OPSC.

In addition, they suggested using the guiding principles from the 2013 article “Talking with Patients about Other Clinicians’ Errors” for any harm response. Specifically:

• Patients and families come first;

• Explore, do not ignore; and

• Institutions should lead.

What More You Can Do

1. Review your harm response policies and procedures to include the recommendations from the Center for Harm Response and MACRMI. 

2. If you completed the Patient Safety Survey, check out your dashboard to see the aggregate results for similar facilities!

3. Participate in the Patient Safety Reporting Program (PSRP) and make sure you have access to all the benefits of this important patient safety resource!

Resources

• Gallagher TH, Mello MM, Levinson W, et al. Talking with Patients about Other Clinicians’ Errors. New England Journal of Medicine. 2013;369(18):1752-1757.