A patient, Mr. Shah, is admitted to a hospital for routine surgery. During the pre-operative process, a nurse administers a medication to prevent blood clots. However, due to a mix-up in the medication administration system, the wrong drug is given—one that Mr. Shah is allergic to.
The nurse realises the mistake shortly after, but the incident is not communicated effectively to Mr. Shah or his family. The nurse documents the error in the patient’s file but doesn’t inform Mr. Shah about what happened, nor does the doctor follow up with the patient to explain the situation. The nurse assumes that the physician will address the mistake during the post-op rounds, but the doctor is unaware of the error until after the surgery, and only then does he contact the patient’s family to inform them and complete the Duty of Candour requirements.
In the meantime, Mr. Shah begins to experience mild allergic reactions after the surgery. His symptoms are not immediately recognized because he doesn’t know to report them as possibly related to the medication error. By the time the issue is identified, the allergic reaction has become more serious, requiring additional treatment and prolonging his recovery.
Key Communication Failures:
In this scenario, poor communication contributed to the safety incident escalating and the patient’s condition worsening, emphasising the importance of clear, transparent, and timely communication in healthcare settings.
Using this case study - apply the principles of good engagement for patients and families (on the right had side) and try to explore where the incident went wrong and what we could have done differently. What does an ideal or gold standard family engagement look like for Mr Shah and his family?
Here are five key principles for good engagement with families following a patient safety event:
1. Openness and Honesty: Engage with families transparently, offering clear communication, acknowledging what happened, and being forthright about the review process. Take responsibility where necessary, and ensure that explanations are consistent and truthful.
2. Empathy and Compassion: Show understanding and sensitivity to the emotions of the patient and their family. Provide authentic warmth, listen actively, and acknowledge their feelings, ensuring they feel heard and valued throughout the process.
3. Timely and Clear Communication: Initiate contact early, providing guidance on what will happen next and ensuring regular, consistent updates. Establish agreed-upon methods and frequency of communication to avoid leaving families wondering about progress.
4. Collaboration and Inclusivity: Involve families as equal partners in the process. Invite their participation in reviews (e.g., After Action Reviews), ask for their questions, and ensure they feel included in the dialogue, contributing to learning and improvement.
5. Accountability and Learning: Take accountability where appropriate and ensure the family is informed about what steps are being taken to prevent future incidents. Share the learning outcomes with both the family and staff, showing a commitment to improvement and safety.
These principles emphasize transparency, empathy, timely communication, collaboration, and accountability to foster trust and ensure meaningful engagement with families.