Pitfalls in Emergency Medicine

-The Implications-

Dr Abu Hassan Asaari Abdullah

MBBS FRCS FAMM
Senior Consultant and Head
Emergency Department
Hospital Kuala Lumpur

Introduction
Pitfalls, bloops and blunders in medical
practice are present in all medical practice in
all over the world
In Emergency Medicine - literatures states that
eliminating complaints and error 100% is
impossible
Nevertheless, each pitfall provides invaluable
lesson and if tapped will prevent undesirable
consequences

First Class

Vision
Mission
System
Facility
Target

BUT
Third Class

Pak Lah 2007

Delivery System
Attitude
Mentality
Implementation

Pitfalls:
To have pitfalls in 24hr heavy duty and
high performing organization is expected
NORMAL
..but
To permanently and repeatedly have
pitfalls is a crime.
An organization must be a learning one.

Implications from pitfalls

in Medical Practice

Patient
Practitioner / Drs
Institution
Profession
Society & Public

Implication to Patient

Morbidity and mortality implications

Psychological
Self worth and self esteem
Anger
Distrust
Change of perception
Compliance

Implication to Practitioner

Actions by organization
Negative reaction by pts and relatives
Decreased self-esteem
Lost of interest in work
Legal implications
Psychological
depression, suicidal etc
*Early Burn Out Syndrome*

Implications to Institution

Corporate Image
Negative publicity and image
Political intervention and implications
Financial Impact
Morale and team spirit
Lost of public confidence
*BRANDING*

Implications to Profession
Negative image
Pressure of education system reform
Disrespect among professionals
Decrease source of sponsorship
decrease chances of recognition of
training programmes
Witch-hunting

Suicides among
physicians.

On average, the United States loses the

equivalent of an entire medical school class
each year (approximately 250 physicians) to
suicide.
Depression is at least as common in the medical
profession as in the general population, affecting
an estimated 12% of males and 18% of females.
Depression is even more common in medical
students and residents, with 15-30% screening
positive for depressive symptoms.

Suicides among
physicians.
Suicide is 2nd most common cause of death
among medical students after accidents in
USA.
Female physicians attempt suicide far less
often than their counterparts in the general
population but completion rates equal those of
male physicians and, thus, far exceed that of
the general population.

Implications to society

Distrust
Disrespect
Pressure to change and comply
Change of choice of treatment

One can choose to

make a choice.
.but he cannot
choose the
consequences of the
choice he makes

USA.some recent
statistics

From USA National

Statistics
44,000 and 98,000 people die in
hospitals annually each year due to
preventable medical errors.
A survey of doctors and other adults
released in December in the NEJM
> than 1/3 of the drs said they or their family
members had experienced medical errors,
most leading to serious health
consequences.

From USA National

Statistics
98,000 patients may be killed each year
in hospitals alone as a result of medical
errors.
Cost to society in terms of disability and
health care costs, lost income, lost
household production and the personal
costs of care are estimated to be
between $17 billion and $29 billion.

From USA National

Statistics

Medical students at SUNY-Buffalo were

asked to recall incidents during their
clinical training that raised ethical
concerns.
More than 200 students responded (40%
of total sample); the majority of instances
they reported (60%) did not in the
researchers opinions threaten the
patients life, health or welfare.
This implies that potentially 40% did.

From USA National

Statistics
6-10% of psychiatrists surveyed confessed to
having engaged in sexual contact with a
patient
Recent alcohol use was extremely high (87%
within the last year for emergency medicine
residents; 74% within the past 30 days for
surgery residents).
An in-depth interview with 53 family physicians
revealed that 47% of the doctors recalled a
case in which the patient died due to physician
error.

Malaysia.some
recent statistics

Complaints received in 2006

Medical Practice Division, MOH
Nature of Complaint
60
50
40
30

percent

20
10
0

Unsatisfactory
service

staff
m isconduct

pow er m isuse

lateness

others

N=251

Complaints received in 2006

Medical Practice Division, MOH
Complaints against
60
50
40
30

percent

20
10
0

doctors

nurses

MAs

drivers

others

N=251

60

Complaints received in 2006

Medical Practice Division, MOH
Complaints via :

50
40
30
20
10
0
letter

media

email

telephone

others
N=251

Negligence Suits Settled

60
50
40
30

Total

20
10
N=251

0
2000

2001

2002

2003

2004

Negligence Suits Settled from 2000-2006

Ringgit
Malaysia

1600000
1400000
1200000
1000000
800000
600000
400000
200000
0
O&G

Surgery

Ortho

Paeds

Anaes

Medical

Total : 61 cases ; RM 3,475,735

Eye

ENT

Uro

Facts
186 negligence suits pending in courts as of
October 2007
Government paid RM 3.47 million in damages
from 2000-2006
Obstetrics and Gynecology account for 4 out of
10 negligence cases
Half of all complaints received by Medical
Practice Division are against doctors
Experts say negligence due to doctors not
communicating with patients

Facts
O&G accounts 44% of 61 negligence
cases (from 2000-2006) settled out of
court (in total RM 1.54 million in
compensation money paid out)

Facts
Medical Protection Society largest
indemnifier of private doctors is recording
largest number of negligence from the O&G
discipline cover for more than 3000 private
doctors in Malaysia
By average, government has settled 9 cases of
negligence per year for the past 7 years
But last year there was a spike of 16 cases

Some examples of
pitfalls in medical
practice
To avoid the pitfalls, its better to
invest with a trusted
Professional organization.

Example 1
Lim Que Moi had a surgical gauze left
after ovarian surgery in Malacca

Example 2
Norizan Ismail died 4 years after
accidental transfusion of HIV infected
blood after giving birth at district hospital
in Johore

Example 3
Landmark ruling of Federal Court: Foo Fio Na
vs Dr Soo Fook Mun & Anor- doctors have the
duty to explain the risk to their patients before
performing critical operations :
Foo was paralyzed 25 years ago after spine
operation to correct dislocated cervical
vertebra following car accident
Foo was awarded RM 1.2 million in damages
including interest

Example 4
Baby Lai Yok Shan lost her left forearm
to gangrene after houseman inserted IV
antibiotics into the artery instead into the
veins

The Equation Of Performance

Workload Vs Capacity Performance

1. High
Low
Negative
2. Low
High
Positive
3. Mod
Mod
Balance

Grading Of Pitfalls and Complain

Grade 1 Individual Emotions and
feelings.
Grade 2 Department Image and
Confidence.
Grade 3 Organization Physical and
financial.
Grade 4 Moderate Impact Physical and
Financial
Grade 5 Sentinel morbidity and mortality

Analysis
WORKLOAD CAPACITY = PERFORMANCE

NEGATIVE

PERFORMANCE
PERFORMANCE

WILL GET

COMPLAINTS

POSITIVE NO COMPLAINTS
- NORMAL FUNCTIONING
- COMPLIMENT

Analysis
WORKLOAD OVERWHELMING CAPACITY
SERVICE DELIVERY SYSTEM FAILURE

Client
Dissatisfactions
Complaint

Resource
Depression

Personnel
Early Burn
Out

Structural
Wear & Tear

Emergency Medicine the

potential risks in the future

The high number of encounter with public

Challenges in waiting time
Challenges in diagnosis and treatment of early
phase of diseases
No benefit of hindsight, time and investigation
results
The place where patients and families are in
miseries
Young and fresh staff not adequately trained
Pressure and demands of receiving referrals

What do we learn?
Complaints will never stop
Complaints welcome is a burden halved
Take measures to avoid pitfalls
training,pre-conditioning,
CCTVs,heightened supervision
Educate patients
Treat pitfalls as oppurtunities

Choose the route of

wisdom..

In each complaint,
there are
opportunities.

Opportunities in pitfalls
and complaints

Opportunity to learn
Opportunity to explain current condition
Opportunity to request for assistance
Opportunity to improve situation
Opportunity to set new goals
Opportunity to prevent recurrence

Choose to.
avoid making mistakes or minimize chances of
making mistakes
always have a good heart and intention
be honest in thyself
not to assume things look into what makes
the word ASS..U..ME and you will know why
document all advices and even steps taken
when pitfalls occur
learnespecially from the mistakes of others

The Way Forward

Change of perspective to pitfalls and
complaints they are oppurtunities to improve
care in Emergency Medicine
Sound complaint management system will be
the way of the future
Need for standardized data on complaints with
categories and weight of error documented
A documentation of pitfalls to be produced in
yearly book will become priceless source of
information

Learning Organization
through the Mx &
Analysis of Feedback
& Complaints

Opportunity comesOpportunity goes

Learning Organization
An organization which adopted a
Continuous, Dynamic & Flexible
knowledge development CULTURE
through a proactive learningby critical
analysis of

feedback,
experiences and
complaints

This is the culture of our Services

Definition:
Complaint :
An expression of dissatisfaction by the
customer .
- A genuine grievance .
- Everybody has a right to complaint
Natural Justice
- Procedural fairness
- Open & Transparent Process

Customer Complaints :
Main areas of customer complaints:
1. Service
2. Quality
3. Relationship
4. Availability
5. Timeliness / Promptness
6. Value for money/effort
7. Truth in labeling & representation
8. Trust

Waiting Area
Management of Wait

Feedback
Feedback Sharing & Providing comment on the
experience after being through the service
system
A proactive & continuous system of getting
feedback eg.
-Client satisfaction survey
-Suggestion box MUST be instituted in a
learning organization
-SELF EVALUATION System in place.

Feedback
A feedback through an
experience.should be a FUEL to the
engine of change in service system
!!!NOT to be treated like a cake of
soap, USED & FLUSHED into the
drain.

What is a Complaints
System?
A system to handle complaints & to
continuously improve the service
- A PRO ACTIVE service ,
Not a reactive service.
However : most complaints are dealt in a
reactive way.

QUALITY MX POLICY
1. Top Management Policy should establish
an explicit customer focused complaintshandling policy.
2. The policy made available to customers
and other interested parties.
3. The policy supported by procedures, and
objectives for each function and personnel
role included in the process.

QUALITY MX POLICY

1.
2.
3.
4.

When establishing the policy & objectives for the

complaints-handling process, the following
factors should be taken into account:
Any relevant statutory & regulatory requirements.
Financial, operational and organizational
requirements
The input of customers, personnel & other
interested parties.
The policies related to quality & complaints
handling should be aligned

Background:
Complaint Management
* Complaints to any organization or
business which are managed well will
benefit that organization.
* Improper management of complaints will
cause loss of customers.
* Strive to translate effective complaints
management into stellar client retention

Issues
Complaint Handling
Problem:
Complaints not managed well
No effective framework for handling
complaints
Complaints handling seen as a defensive
manouvre / reaction.
Complaints are not capitalized upon to
cause improvement in the service.

Complaint Handling
Paradigm shift
See the complaint as a gift.
Treat the complaint with a positive
connotation.
The complaint as a form of feedback
from the client.
The complaint as an opportunity.
Turn the Critic into an Advocate.

Complaint Handling
Paradigm shift .

Welcome complaints
Easy to access complaint system
Treat complainant with respect
Responsive complaint system
Empowered to find solutions
Proper training in handling complaints
and complainant

Complaints Management
2 main principles in complaint management:
1. Commitment
2. Fairness

Embedding the procedure as a

culture in the organization.

7 SINS OF POOR SERVICE

1.
2.
3.
4.
5.
6.
7.

Apathy to customers dont care

Brushing off customers
Being cold to customers. Unfriendly.
Condescending to customers
No eye contact robotic
Too rigid bound by rules
Giving customers the run-around

Frontline Public Relations

Skill
1.
2.
3.
4.
5.

Smile genuine smile

Open posture look & act interested
Forward lean
Eye contact
Nod your head. Signal your interest.

TRIAGE
Public Relation Skills

Proactive Triage

Static Triage

Triage Counter
Fly Eye Concept

Smile ! Please.

Complaints Management
The complaint is not a threat !
In the corporate world if your customers
complain - you still have a customer.
If they dont complain you have lost that
customer! They will leave and bring their
business somewhere else !

Complaints Management
The complaint
Manage, resolve and case closed
The cause of the complaint
- Root cause investigation
- Why did it happen?
- Who was responsible?
- Who is the problem owner?

Process Mapping the key drivers of

complaints
Work Process Flowchart : Ideal Delivery System?
Work Process 1

?
Where is the problem ?

Work Process 2

To deviate resources?

- Points of Pain
- Root cause investigation
- In depth Analysis

To ignore?

Work Process 3

Work Process 4

Service / Product

To change our work

process?

Principles of Complaint Handling

1. Commitment (Leadership) must have a policy,
objectives, clear procedures, signed by the
chief
2. Fairness (Fair & Reasonable)
3. Remedies All issues addressed? Appropriate
follow up?
4. Data collection
5. Data analysis to propose solution
6. Accountability

The complaints ESCALATOR

Question: At
what level do
you need to
intervene?

escalator
Persistent
Complainant / Issue
/ Problem

Systemic & recurring complaint

occurs more than once

Occurs
Once

Transactional complaint fixed

at point of complaint ( Fixed &
Finished) Client satisfied or
dissatisfied.

Must be
documented

Problem OWNERSHIP
Issue : Who is the actual problem owner?
Must engage the internal stakeholders
Issues :
Problem owner does not acknowledge or act
upon the problem. Ignorance !
Lesson identified - BUT NOT LEARNED!
Problem made worse - escalation.

Complaints Handling
NO BLAME CULTURE ! the system
is at fault.
DO ITDONT JUST SAY IT.!
JUST THE FACTS
Correcting the system
Identify levels of causation.
Conducting the investigation to find
levels of causation.
Root Cause Analysis Models..

Complaints Management
Need to create an effective complaints
prevention and service recovery
framework Investigations & RootCause- Analysis

Complaints Management
Basic Methodology/Process:
Issue

Analysis

Strategy Win-win outcome

Both parties have resolution

Strategy

Complaints Management :
A practical framework
Issue / Problem

Analysis

Eg:
1. Personality
1. Rude Doctor 2. Social
Background
3. Family
4. Finances
5. Work
environment
6. Excessive
Work load

Strategy
1.
2.
3.
4.
5.

Counseling
Advice
Support
Warning
Last resort Punitive
action

CONTROLS & STATUS REPORT

Principle

Requirements

Current
situation

Rating

Improvement
recommendation

Need for Review of Complaints Mx

Top management of the organization
should review the complaints-handling
process on a regular basis to ensure:
- continuing suitability, adequacy,
effectiveness and efficiency.
To identify and correct:
- non conformity with standards
- product/service deficiencies
- process deficiencies

Need for Review of Complaints

Mx
To assess opportunities for
improvement and the need for
changes to the complaints-handling
process & products offered.
To evaluate potential changes to the
complaints-handling policy and
objectives.

Scoring the Complaints Management System

Score
1

Situation
No Idea whats going on!

Some Idea but little or nothing done

Some actions on procedures and behaviours but not

finished

Finished, in place, communicated and operating

Finished, in place, communicated and operating

For more than one year with completed
internal/external review and relevant corrective
actions.
WHERE IS YOUR ORGANIZATION SITUATED?

Self Evaluation Of Intervention

Management of complaint must deliver
a quantifiable outcome

Reduction of complaint
Positive feedback
Complementary letter
Motivated personnel

Caring Heart From Caring Home

Critical analysis of situation

NEVER !!!
Blame the personnel without evidence
MUST !!!
Be fair to personnel by understanding
every aspect of complaint

MA R & R..

Staff Nurse Pantry

Conclusion
Make complaint and feedback
.Building blocks of reorganization
.Catalyst for change
.Motivator for leadership
.Enhancer for teamwork
THERE IS LIGHT AT THE END OF THE
TUNNEL.

ONLY A FOOL LEARNS FROM

EXPERIENCE.
I LEARN FROM THE EXPERIENCE OF
OTHERS.
Otto Von Bismarch 1815-1898

Thank You