Page 52 - ACCCN's Critical Care Nursing

Resourcing Critical Care 29

1. The provider owed a duty of care to the recipient. of strong, dedicated and collaborative leadership from
2. The provider failed to meet that duty, resulting in managers as the key to organisational success in the
a breech of care. critical care setting. (See Chapter 1 for a discussion of
3. The recipient sustained damages (loss) as a result. leadership.)
4. The breech by the provider caused the recipient to
suffer reasonably foreseeable damages. 68 MANAGING INJURY: STAFF, PATIENT
OR VISITOR
Negligence is a technical error that can be proved in a
court, although it does not follow that a negligent person When staff members are injured, the response must be
is incompetent; in fact, many clinicians and managers swift and deliberate. Injury can come in many forms,
have probably been technically negligent, it’s just that involving physical injuries or biological exposures, for
their errors have yet to be discovered! When managing in example. More often, the problems are grievances, such
this context, the best hope is that the frequency of errors as missing out on an opportunity afforded to others (e.g.
or negligent actions will be reduced by putting into place a promotion), feeling marginalised by others, or not
systems that prevent such errors from occurring. 66 getting a preferred roster.
THE ROLE OF LEADERSHIP AND For families and patients, an injury can be physical, such
as a drug error or an iatrogenic infection; however, the
MANAGEMENT injury can also be non-physical, as with complaints about
Managers must also be leaders, and the need to have good lack of timely information, misinformation or rudeness of
leaders and managers is as relevant to critical care as it is staff. In all circumstances a manager needs to intervene
to any other business or clinical entity. Research on proactively to minimise or contain the negativity or harm
organisational structures in ICUs across the USA in the felt by the ‘victim’. Regardless of the cause of the injury, the
1980s and 1990s demonstrated the important role principles governing good risk management are common
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leadership plays in patient care in the ICU. Using APACHE to many situations and are summarised in Box 2.4.
scoring, organisational efficiency and risk-adjusted sur-
vival were measured. High-performing ICUs demon- If an incident does occur, it is always prudent to docu-
strated that actual survival rates exceeded predicted ment the event as soon as possible afterwards and when
survival rates. it is safe to do so. The clinician who discovers and follows
up an incident must document the event, asking the
Further investigation and analysis of the higher- questions that a manager, family member, police officer,
performing units noted that these units had well-defined lawyer or judge might wish to ask. The written account
protocols, a medical director to coordinate activities, provided soon after the event or incident by a person
well-educated nurses and collaboration between nurses closely involved in, or witness to it, will form a very
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and doctors. Clear and accessible policies and proce- important testimonial in any subsequent investigation
dures to guide staff practice in the ICU setting were also (Table 2.6).
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highlighted. These need to be in written form, simple Contemporary wisdom in modern health agencies advo-
to read and in a consistent format, evidence-based, easy cates open disclosure: telling the truth to the patient or
to understand and easy to apply. Box 2.3 shows a possible family about why and how an adverse event has
format for clinical policies and protocols.
occurred. 71,72 This practice may be contrary to informed
The latter study showed similar characteristics: they had legal advice and may not preclude legal action against the
a patient-centred culture, strong medical and nursing staff or institution. 73–75 However, openly informing the
leadership, effective communication and coordination, patient/family of what has occurred can regain trust and
and open and collaborative problem solving and conflict
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management. One cannot underestimate the value

BOX 2.4 Defensive principles to minimise
BOX 2.3 Sample headings to define a policy risk after an incident (patient or staff) 21

● Policy ● Those persons encouraged to participate in decision
● Rationale making are more inclined to ‘own’ the decisions made;
● Procedure therefore, involve them in deciding how the issue is to be
● Statistical reports (e.g. to measure compliance with or tackled and help to make the expectations realistic.
outcome of policy) ● Education of the person in the various aspects of the
● Other information incident/activity will reduce fear and anxiety.
● Contact person ● Explain the range of possible outcomes and where the
● References affected person is currently situated on that continuum.
● Filing instructions ● Provide frequent and accurate updates on the person’s situ-
● Date of issue ation and what is being done to improve that situation.
● Date for review ● Maintain a consistent approach and as far as possible the
● Signature and designation of authorising officer same person should provide such information/feedback.