MODULE 3 MODULE 4 MODULE 5 MODULE 2 ETHICS ISSUE 2: Professionalism in Patient Care—Truth Telling 2. Ethical 3. Ethical 4. Best 5. Metric 6. Current 7. Reality 8. 9. Refined Improvement 1. Ethics Issue Standard Standard Practice Ethics Check Goal Goal Source(s) Description(s) Practice “Should” “Is” with Exclusions The quality VHA There is an Adverse Numerator: Current practice 1. Starting manager for ethical events that was determined Point Number of surgical 1004.08 obligation to cause harm to by identifying all events found a Disclosure to patients patients on adverse events that caused number of of Adverse harmful adverse surgical that caused harm harm to patients in Events to events that have should to patients on that were which adverse Patients been sustained in be disclosed surgical services to events that t he course of to the patient over the past 6 2. Seriousness patients or caused harm care, including or months through a personal should have cases where the personal review of incident representatives been disclosed harm may not be representative reports. The ____________ to patients or obvious, or where [unless patient of these Denominator: personal there is potential is deceased, patients were were for harm to occur incapacitated, Total number of reviewed for a 3. Environment not disclosed. in the future. or otherwise disclosure note. adverse events unable to take that caused Currently, 65% of part in the harm to patients adverse events Exclusion(s): and on surgical that cause harm Patient is there is no to patients on personal surgical services Method: 4. Challenge incapacitated, or are being Record review otherwise unable disclosed to to take part in the Sample size: or pro-cess, and 100% personal there is no representatives. Time frame: Past 6 months representative.
MODULE 2 MODULE 3 MODULE 4 MODULE 5 ETHICS ISSUE 2: Professionalism in Patient Care—Truth Telling 1. Ethics Issue 2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Practice “Should” 5. Metric 6. Current Ethics Practice “Is” 7. Reality Check 8. Goal 9. Refined Improvement Goal The quality manager for surgical found a number of in which adverse events that caused harm should have been disclosed to patients or personal were not disclosed. VHA 1004.08 Disclosure of Adverse Events to Patients There is an ethical obligation to to patients harmful adverse events that have been sustained in t he course of care, including cases where the harm may not be obvious, or where there is potential for harm to occur in the future. Exclusion(s): Patient is incapacitated, or otherwise unable to take part in the pro-cess, and there is no representative. Adverse events that cause harm to patients on surgical should be disclosed to the patient or personal representative [unless patient is deceased, incapacitated, or otherwise unable to take part in the and there is no personal Numerator: Number of events that caused harm to patients that were to patients or personal representatives ____________ Denominator: Total number of adverse events that caused harm to patients on surgical Method: Record review Sample size: 100% Time frame: Past 6 months Current practice was determined by identifying all adverse events that caused harm to patients on surgical services over the past 6 months through a review of incident reports. The of these patients were reviewed for a disclosure note. Currently, 65% of adverse events that cause harm to patients on surgical services are being disclosed to or personal representatives. 1. Starting Point 2. Seriousness 3. Environment 4. Challenge
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