VA to increase transparency, communication of adverse clinical events

A new VA initiative is changing how the department informs its employees, patients and their families, and the media about what are called large-scale adverse events.

Such events potentially expose thousands of hospital patients worldwide each year to unsafe clinical practices that stem from systemic and preventable errors. These events can injure many patients or increase their risk of injury but are not detected by the health care system when they occur.

Dr. A. Rani Elwy, a health psychologist and health services researcher at the VA Bedford Healthcare System in Massachusetts, is spearheading the new VA program. It provides verbal and written communication expertise to VA facilities needing to disclose information about heath care to patients, families, employees, and the public.

Dr. Robert Jesse, a former VA principal deputy undersecretary for health, presents Rani Elwy with a certificate of appreciation in 2014 for the work she and her team did to improve how VA responds to adverse events.

This information is in a toolkit that Elwy and her colleagues developed through a VA-funded five-party study that focused on proven communication responses to large-scale adverse events. The toolkit is aligned with a 2018 VA directive – the most up-to-date one of its kind in VA – that establishes a policy ensuring consistency in how VA discloses details about adverse events in clinical care.

Disclosure is `complex and requires quick execution’

In the study, Elwy and her team interviewed leaders, employees, patients and family members at nine VA facilities where large-scale adverse events were disclosed to identify key lessons learned. When reflecting on past events, many leaders and employees felt that they needed resources to help with the communication process. The toolkit, which notes that large-scale adverse event disclosure is “complex and requires quick execution,” was created to help address that need.

Among the messages Elwy and her team gleaned from the research is that it’s unhelpful to Veterans to downplay the risk of an adverse event, and that a health care worker must tell them about the event verbally, not through the mail. When a letter arrives about an adverse event, Veterans may want to talk to a health care worker immediately, Elwy says, noting that they also may not know what to do with the information.

`But you never know’

“Very, very few if any of these Veterans have ever contracted HIV or hepatitis C or hepatitis B as a result of something like this,” she says. “But you never know. So one of the messages is that it would be good for them to come back in and get a blood test just to make sure they’re okay. But anytime you say the word HIV or hepatitis to a Veteran, that’s very scary. It’s better to hear that over the phone so they can ask questions. Then you can say, `We really don’t want to leave anything uncovered. Can you please come back in and have a test?’ As opposed to putting it into words in a letter when they have no one to talk to and may think, `Oh my God, I have HIV.’

“In our toolkit,” she adds, “we try to make sure the language is straightforward, that we’re not trying to say to someone, `Look, you’ll be fine. But we’re just telling you this because we want to tell you.’ We’re trying to avoid any downplaying because it’s unhelpful for decision-making moving forward. It doesn’t help Veterans with what to do next.”

More information

Click here to read the full story.

Click here to learn more about VA research.