When Things Go Wrong Seminar Strategy

QSEN Institute

Submitter Information

Author: Elizabeth C. Kudzma, DNSc MPH
Title: Professor, Division of Nursing
Institution: Curry College
Email: ekudzma@curry.edu

Competency Category(s)
Safety

Learner Level(s)
New Graduates/Transition to Practice, Pre-Licensure ADN/Diploma, Pre-Licensure BSN, RN to BSN, Staff Development

Learner Setting(s)
Clinical Setting

Strategy Type
Case Studies

Learning Objectives

(Modified slightly from QSEN competencies)
  • Communicate observations or concerns related to hazards and error to patients, families, and the health care team
  • Describe factors that create a culture of safety, for example, open communication strategies and organizational error reporting systems
  • Appreciate the cognitive and physical limits of human performance
  • Value vigilance and monitoring by patients, families, and other members of the health care team
  • Value own role in preventing errors

Strategy Overview

“When Things Go Wrong” is an evidenced-based consensus statement created by the Harvard University teaching hospitals to address unanticipated adverse events in the clinical setting. The document urges the use of open and rapid disclosure to patients and families who have experienced serious unanticipated medical events. It is linked on the QSEN web site and can be accessed directly at this web address:  https://www.qsen.org//annotated_bibs.php?id=402. The document stresses two important points: medical care should be safe and patient-centered. The document also addresses support and education for clinicians involved in adverse incidents.
The original purpose of the document was to gain agreement on principles individual hospitals will use when managing the aftermath of such events. The document invites elaboration and use of a wide variety of initiatives in implementation. Agencies employing nurses are obligated to increase their commitment to care for the patient harmed, and change systems to prevent future error. Several of the hospitals listed within the document are used for student clinical experiences at our college.
Faculty decided to dedicate a clinical seminar early in the semester for the senior precepted clinical experience for discussion of this document. A PowerPoint summary of the document was created and students were asked to view that along with the original document (on the student’s Blackboard site) prior to the seminar time. Students were also requested to fill out a short response sheet after reading the document, and to bring this to the seminar. The response sheet included two open-ended questions:
1. How do you feel about the guidelines shown in this document.
2. How can you use this information to impact your future practice?
These response sheets were collected at the end of the seminar session.

Submitted Materials

Additional Materials

Evaluation Description

The responses of the students indicated that many QSEN KSA’s can be addressed in one seminar exercise. The faculty were asked to mention that some parts of the document may be controversial and that nurses should be guided by the policies of their employing institution. Virtually all of the students indicated that it was important to have written guidelines about how (and who should) communicate with patients about adverse events. Many students mentioned that it was helpful to think ahead of time about what could go wrong in a patient situation and the best protocols to guide communication with patients and families. Others stated that the exercise made them more aware of different types of patient errors. Students commented that they would be more likely to ask employing agencies about their adverse event protocols. Most of the students mentioned the importance of appropriate communication with patients and families, use of teams to inform patients about adverse events, the importance of building trust with patients, general error prevention and greater individual situational awareness on clinical units. For a few students, this awareness probably increased their anxiety about involvement in a medical mistake, but the seminar format allowed faculty to probe students ‘ reactions and refocus the discussion on prevention of errors.