Medical error catharsis… developing a workable and effective disclosure process

A story on the American Medical Association’s website, Amednews.com, discusses the story of three physicians who decided to share their perspectives on medical errors in which they were involved.   Each physician’s story demonstrates how painfully easy it is to be distracted, make incorrect assumptions and to bypass safety processes designed to avoid errors.  One case, that of a surgeon who inadvertently performed the wrong surgery on the wrong patient highlights how a language barrier, last minute change of venue and a lack of attention to detail were each contributing factors to the error.  The story cites an Archives of Surgery study which found that about 250 physicians per year commit suicide and that this represents a rate that is double that of the general population.

This study also found that physicians who believe they have committed a medical error are three times more likely to have suicidal thoughts than the general physician population.  However, the case study cited is that of a critical care nurse at Seattle Children’s Hospital that miscalculated the dose of Calcium Chloride required for an 8 month old child by ten fold resulting in the baby’s death.  This, together with the loss of her job and professional license apparently led to her committing suicide.  Many health professionals agree that they hold themselves to a high standard of performance and when they commit an error, rather than focus on the causative factors that contributed to the error, they hold themselves solely responsible.

In assessing the culture of patient safety at multiple organizations, I often find that many clinicians and their managers are not as well versed in their facility’s policy on post-adverse event disclosure as they should be.  It appears then, that many organizations do not devote the energy necessary to develop a workable set of guidelines to properly disclose errors to patients.  Staff need to be involved in the development of these guidelines and the disclosure process should be shared in scenario based workshop training coupled with education around performance improvement and risk mitigation initiatives to allow staff, administrators, quality and risk managers to prepare for the time that these skills will be necessary.  Among the links at the end of this post are a policy/guideline from the University of Michigan Hospitals and other resources discussing the ethics of and strategies for disclosure of medical errors.

Beyond immediate disclosure to a patient, perhaps the best way of sharing medical error experiences is to report them to a patient safety organization, like the Institute of Safe Medication Practice (ISMP), and at some point in the near future, at PatientSafetyHub.com.  Patient Safety Organizations (PSO’s), a byproduct of the Patient Safety Act provide an element of protection to professionals and organizations that report their medical errors.  According the the Agency for Healthcare Quality and Research (AHRQ), the goals of the Patient Safety Act are to encourage the expansion of voluntary, provider-driven initiatives to improve the quality and safety of health care; to promote rapid learning about the underlying causes of risks and harms in the delivery of health care; and to share those findings widely, thus speeding the pace of improvement. The Patient Safety Act:

  • Encourages the development of Patient Safety Organizations (PSOs)—organizations that can work with clinicians and health care organizations to identify, analyze, and reduce the risks and hazards associated with patient care.
  • Fosters a culture of safety by establishing strong Federal confidentiality and privilege protections for information assembled and developed by provider organizations, physicians, and other clinicians for deliberations and analyses regarding quality and safety.
  • Accelerates the speed with which solutions can be identified for the risks and hazards associated with patient care by facilitating the aggregation of a sufficient number of events in a protected legal environment.

A number of links to informational and best practice references, useful in the development of a workable disclosure policy can be found below.  As one of the goals of this blog is to provide a screened reference hub for information that is valuable in the development of safe medical practices, I would appreciate it if users would provide information on additional links that have been useful in their personal research on the subject.  JH, RPh

 

References and Links:

1)  Revealing their medical errors.  Why three doctors went public?  Kevin B. O’Reilly (Amed News)

2)  Recognizing and Disclosing Medical Errors.  Ann Freeman Cook and Helena Hoas (Ch. 12: Ethics conflicts in rural communities)

3)  Guidelines on how to disclose medical errors or negative outcomes

4)  Medical Error Handbook

5) A conceptual model for disclosure of medical errors (nih.gov)

6)  Respectful Management of Serious Clinical Adverse Events (IHI Innovation Series White Paper 2010)

7) Ohio Government plays Whack-a-Mole with pharmacist (ISMP Medication Safety Alert 8/27/2009)

8)  The Physician’s Guide to Patient Safety Organizations (American Medical Association)

9) Policy: Disclosure of Medical Errors (Christus Santa Rosa Healthcare; 2007)

10) Disclosing Medical Error (Bradley and Brasel; Medical College of Wisconsin)

11) Medical Errors, Disclosure and the role of Apology: A tool for Physicians (Texas Medical Liability Trust)

 

 

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3 Responses to Medical error catharsis… developing a workable and effective disclosure process

  1. BethanyB says:

    A very timely topic as my Director just asked me to research this on my project day this week. I found a good site on talking about errors with patients at http://depts.washington.edu/toolbox/errors.html

    It says “Patients want physicians to explicitly state than an error occurred, describe what the error was and why the error happened, how error recurrences will be prevented, and to apologize.
    In most cases, disclosure does not appear to stimulate lawsuits, and may in fact make lawsuits less likely”

  2. gp2 says:

    Thanks for posting this Jamal. There’s a great cite in the BMJ from earlier this summer “Sorry doesn’t need to be the hardest word”.
    http://www.patientstories.org.uk/wp-content/uploads/WhySorry.pdf

  3. Josh_83 says:

    The book Medication Errors 2nd Edition by Michael Cohen has a whole chapter devoted to disclosing errors.

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