Root Cause Analysis & Error Disclosure Workshop, Spring 2024

Error Disclosure Plan Worksheet

Please use this worksheet to prepare and document your team’s error disclosure plan. At the completion of
this small group activity, please submit a copy of our team’s completed worksheet (one worksheet per team)
to ipe@pnwu.edu.
1. List the team members present in your small group – include their full name and program:
3 DO students
1 DPT student
Autin Walker, OT

2. Review & discuss the patient case and prepare to complete your cause & effect (fishbone) diagram.
Come to a consensus as a team on what happened (What was the error? What should have happened?).
Use the five "whys" to identify potential causes and complete your fishbone diagram on pg. 2.
Error: Incorrect phone number
Should have happened: corrected/verified phone number on repeat visit during US

Why's?
No alternative numbers or other forms of contact listed
Busy radiology staff
New staff (administrator in charge of protocol)
Updated hospital EMR changing format

3. Use the text box below to plan for what you will say to the patient, or the patient’s family member,
when disclosing the error. Identify how the error disclosure will be conducted as a team. Include
the following elements in your plan:
a. Introduction of team to family member – develop rapport
b. Acknowledgement of the error – apology, demonstrate empathy
c. Explanation of what happened – in lay language, assure the family member
d. Plan for follow up and further action – patient care, system improvement
a) Introduce ourselves to patient or family member and state which department we are from. See
how patient and family are doing
b) Give em the news, phone number entered incorrectly leading to absence of notification on
positive chlamydia test results. Take responsibility. Give patient/family time to ask questions.
Resonate with how the patient is feeling at the moment.
c) Incorrect phone number so we were unable to get in contact with the patient. On repeat visit we
failed to notify the patient that there were 4 unanswered calls about her lab results. This could be
due to new EMR, busy floor, and new staff; either way we take responsibility and are sorry.
d) New system and new staff. Confirm their number at this time and ensure them that we are
training staff with the new EMR and ensuring staff double checks important information such as
contact information. Express that we care for every patient that comes to us.
 Cause and Effect (“Fishbone”) Diagram

People Method Equipment

Radiology staff Lack of Updated EMR

coordination

Nursing staff No protocols in Phone system

place

Clinic supervisor Method of No trigger for

contact urgency Delay in
Treatment
Leads to
Complications
Chlamydia lab Mail delivery
test

US Understaffed

Documentation Busy floor

Material Environment

Template Source: University of Iowa Hospitals and Clinics

 Root Cause Analysis & Error Disclosure Workshop, Spring 2024

After delivering the error disclosure, discuss the following within your team and document your comments in
the fields below:
1. How did the team feel based on the patient or family member’s reaction?
A little bit of shock. Surprised to hear that the patient did in fact receive the phone calls that we
sent her. We still felt remorse for the patient and what had happened, but we did not feel
prepared for the discussion we had. Overall it went well.

2. How did you feel when you worked as a team? What went well? What could have gone better?
What went well: Planning follow up with counseling or therapy for the patient because she was
distraught. Empathy and remorse.
Improvements: refer to follow up with OB/GYN. Team work, although difficult over zoom. Share
the information we got and cross match that with what clients Mom knows.

3. How were team roles decided?

Austin was primary speaker and we were on call for backup if he needed assistance. A DO
student was note taker.

4. How did you apply your values & ethics in evaluating and disclosing the error?
Austin related personally with his son expressing family values and building rapport with the
mother. Ethics of "do no harm" as a standpoint.

5. How did you manage differences in beliefs?

Supported and reassured the mother while still expressing differences. Apologizing for
miscommunication. Were not defensive about having the correct phone number. Addressed the
miscommunication and kept moving forward.