Failure to Rescue a Recurring Post-Surgical Event (Claims Corner CME)
Description
Claims arising from the perioperative experience are frequent, often preventable, and some of the costliest claims for physicians. One study of surgical claims conducted by The Doctors Company noted that about two out of three general surgeons have been involved in a medical malpractice suit. Malpractice data consistently finds that the most serious and common post-operative complications are unrecognized intestinal puncture or perforation. Diagnostic error by surgeons involving unrecognized intestinal puncture or perforation of an organ can quickly lead to septic shock and death.
Failure to rescue (FTR), a publicly reported quality measure, is the occurrence of mortality after a major surgical complication. FTR can occur when communication between providers and with patients is poor, there are delays in the recognition of post-operative complications and/or when there is mismanagement of a complication by the clinical team. The following case illustrates a cascade of events that led to FTR. It highlights the need for clear communication, recognition and exchange of clinical findings and impressions, and collaboration between clinicians during intra and interhospital transfers.
| Course ID #: | TDE 231298.0 | Issue Date: | 5/31/2023 | Expiration Date: | 5/31/2026 |
Desciption of the Professional Practice Gap (PPG)
Failure to rescue (FTR) can occur when communication between providers and patients is poor, recognition of post-operative complications is delayed and/or mismanaged by the clinical team.
Learning Outcome
At this activity's end, learners will know and immediately apply critical handoff communication techniques during interhospital and post-hospital care transfers to improve patient safety.
Learning Objectives
After completing this activity, learners will be able to:
- Reflect on your experience and how a delayed or missed diagnosis of a surgical complication could have led to failure to rescue in the surgical patient or a catastrophic result.
- Modify diagnostic processing and expand the differential diagnosis to decrease the risks of missed or delayed diagnosis in the perioperative setting.
- Evaluate key factors related to communication at transitions of care that led to a failure to establish a diagnosis.
Course Developers
Kimberly Hathaway, MSN, RN, CPHRM, CPHQ, Director Patient Safety Healthcare Quality & Risk Management, The Doctors Company
Johanna Lackner, MPH, MSW, Senior Director, Continuing Professional Development, Department of Patient Safety and Risk Management, The Doctors Company
Continuing Education Credit
The Doctors Company is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical educational activities for physicians.
The Doctors Company designates this activity for a maximum of 0.5 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
No individual in a position to control or influence the content of this activity has reported relevant financial relationships with commercial interests. No commercial support was provided for this activity.
ANCC - Accreditation and Disclosure Statement
The Doctors Company is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.
The Doctors Company designates this activity for a maximum of 0.5 nursing contact hour. Learners should claim only the credit commensurate with the extent of their participation in the activity.
No individual in a position to control or influence the content of this activity has reported relevant financial relationships with commercial interests. No commercial support was provided for this activity.
Disclaimer Statement
This program is being offered for informational and educational purposes only from a Patient Safety Risk Management perspective and does not constitute legal advice. Laws vary from state to state, actual clinical situations often involve subtle differences and nuances from program scenarios or recommendations, and the recommendations provided in this activity may not apply to all practice situations. In complex circumstances, which present significant potential for an adverse event or litigation, TDC and the faculty recommend you consult directly with your corporate or personal counsel for professional legal guidance.
Complies with State Requirements
Please SEE the Federation of State Medical Boards overview of Continuing Medical Education requirements by State.
Please SEE the Registered Nurse and Licensed Practical Nurse CE Requirements by State.
Technical Requirements
The activity is best experienced using the most current browser: Firefox, Chrome, Safari, or Microsoft Edge. Internet Explorer is not supported on this platform. All activities featuring audio must have a speaker. To view graphic images and references that appear in separate "pop-up" windows, JavaScript and session cookies must be enabled on your computer. Adobe Acrobat Reader may be required for certain activities.
Contact Us
If you have questions, contact educationsupport@thedoctors.com or call 800.421.2368.
Resource
Visit our Resource document for this program.