Even in the safest of healthcare systems things can, and often do, go wrong. Just ask Linda Kenney. Linda’s story began in 1999 when she nearly died as the result of an anesthesia mishap. A routine orthopedic surgery scheduled at a large academic medical center went wrong when a local anesthetic administered to her ankle entered her bloodstream and caused a cardiac arrest. Were it not for the heroic efforts of a code team, she would not be here today. Read Linda’s full story here.
The emotional impact that Linda and her family experienced was life changing. But, the healthcare culture at the time didn’t lend itself to open and honest conversations about adverse events. She was told she had an allergic reaction by one clinician, and no one else referenced “the event” again during her hospital stay.
A few months after this incident, Linda visited her orthopedic surgeon. There, she witnessed the emotional impact her event had on a member of the health care team. The orthopedist cried when he talked about it and referred to her as a “miracle from God.” The anesthesiologist who was involved reached out to her right after her event (against the advice of his institution and colleagues). Eventually, when she was ready, Linda was able to sit down with him to discuss their common experience. She kept thinking, “If I’m feeling this badly, how is he feeling? After all, he was the one with the needle that day.”
On the home front, things were challenging as well. Linda’s husband couldn’t look at her without crying, and her three young children were experiencing all sorts of emotions. In the immediate aftermath of her event, Linda needed to focus on her family’s wellbeing, putting her personal needs aside. But, around six months after the event, Linda would experience an enormous wave of emotion for which she was totally unprepared. She felt like she was going crazy, and there was no one to help – no support groups, in person or online tools and resources.
Linda felt compelled to change the system that had let her and her family down (and the clinicians involved) by founding MITSS (Medically Induced Trauma Support Services) in June, 2002. MITSS’s mission, then and now is:
To Support Healing and Restore Hope to patients, families, and clinicians following adverse medical events.
Much has happened since 1999. In recent years, there has been a shift in the way healthcare organizations deal with the fallout from adverse events. A handful of institutions and initiatives, notably the University of Michigan Health System and the CARe (Communication, Apology and Resolution) Program in Massachusetts, have sought to change the way these events are managed by promoting a culture of open and honest disclosure, sincere apology, and early offer when it is warranted. Support for patients and families, and the clinicians involved, is widely considered to be an integral piece to the success of such a program.
Currently, much work is being done around the “second victim” – a term referring to the clinician involved in a bad outcome. Back in 2011, MITSS brought together a blue ribbon panel of experts and developed the Clinician Support Tool Kit for Healthcare. As one of its features, the toolkit contains a fairly extensive bibliography dealing with the second victim phenomenon. We are now in the process of revising and updating the tool kit with the help of a group of national and international experts. We are also looking for feedback from those who have downloaded and are using the tool kit at their institutions.
We wish we could report that the needs of the “first victim” – the patient or family member involved – were receiving equal attention. Unfortunately, there are no established best practices, no movement afoot to operationalize patient and family support programs. And, there is very little funded research being done on the subject. There is, however, a social media outcry as more and more harmed patients take to the web, individually and collectively, to voice their dissatisfaction.
Join us, Linda Kenney (@lindakkenney) and Winnie Tobin (@wntobin) from MITSS (@mitss_support), on Tuesday June 10th 2014 at 8:30pm Eastern time for the weekly #hcldr chat (for your local time click here). We’ll talk about emotional support for everyone following adverse medical events. Specifically, we will discuss these topics:
- T1: What are ways to support patients and families following adverse events?
- T2: What are ways to support a clinician after a bad clinical outcome?
- T3: What can we do to ensure support is routinely provided in every institution after an adverse event?
- CT: What’s one thing you learned tonight that you can take back and use to help a patient, a clinician or your organization tomorrow?
Biographical Sketch – Linda K. Kenney
Linda K. Kenney, Executive Director and President of MITSS (Medically Induced Trauma Support Services, Inc.), founded the organization in 2002 as the result of a personal experience with a near fatal medical event, when she identified the need for support services in cases of adverse events and outlined an agenda for change. Since that time, she has been at the forefront of the patient safety movement, inspiring organizations to tackle the challenges that impair effective disclosure, apology, and support programs for patients, families, and staff. She speaks regularly at healthcare conferences and forums, provides in-depth consultations to hospitals and other organizations, and her expertise has been sought on numerous patient safety projects throughout the country and around the globe. In 2006, Linda was the first consumer graduate of the prestigious HRET/AHA Patient Leadership Fellowship. That same year, she was the recipient of the National Patient Safety Foundation’s esteemed Socius Award, an annual award given in recognition of effective partnering in pursuit of patient safety. She has authored and contributed to a number of publications on topics including the emotional impact of adverse events on patients, families, and clinicians. Linda currently serves on the boards of the Massachusetts Coalition for the Prevention of Medical Errors and the National Patient Safety Foundation.
Biographical Sketch – Winifred N. Tobin
Winifred N. Tobin (firstname.lastname@example.org) joined MITSS in the spring of 2003. Since that time, she has been responsible for strategic communications surrounding all of the organization’s activities including web content, print media, social media, annual event planning, and community outreach efforts. Her areas of specific interest include emotional support for anyone involved in an adverse event; patient safety and quality; patient engagement; health literacy; and, safer healthcare for diverse populations. She co-authored Engaging Minorities in Safer Healthcare in 2011. Winnie has served on numerous committees representing the patient’s voice, and, in particular, that of the patient who has suffered medical harm. Currently, she serves as on the Consumer Advisory Group to the Massachusetts eHealth Collaborative, and she is a member of MACRMI.
Tools, Resources and Upcoming Educational Program
Clinician Support Tool Kit for Healthcare http://www.mitsstools.org/tool-kit-for-staff-support-for-healthcare-organizations.html
MITSS: Supporting Patients and Families for More than a Decade, PSQSH, May/June 2013. http://www.psqh.com/may-june-2013/1648-mitss-supporting-patients-and-families-for-more-than-a-decade?highlight=WyJtaXRzcyJd
Disclosure and Apology: What’s Missing? Advancing Programs that Support Clinicians, MITSS white paper. http://www.mitss.org/MITSS_WhatsMissing.pdf
MITSS Tools website for patients/families, clinicians, and healthcare organizations: www.mitsstools.org
Respectful Management of Serious Clinical Adverse Events (Second Edition). Conway J, Federico F, Stewart K, Campbell MJ. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. http://www.ihi.org/resources/Pages/IHIWhitePapers/RespectfulManagementSeriousClinicalAEsWhitePaper.aspx
Building a Clinician Support Program: A MITSS Workshop at the Institute of Healthcare Improvement, July 15 and 16th, 2014. http://www.ihi.org/education/InPersonTraining/MITSS/2014MITSSBuildingaClinicianPeerSupportProgram/Pages/default.aspx