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Patient Safety Tip of the Week
July 11, 2023
Error Disclosure
in the Real World
We’ve done many columns on error disclosure and apology (see
list below). We’ve advocated disclosure since the early 1990’s because it is
the right thing to do and, in the long run, tends to make something positive
come from something negative. Disclosure and apology has
now become accepted on a widespread basis.
But how is it actually working in the real world?
Researchers in France studied this in a neonatal ICU (NICU) setting (Passini 2023). They analyzed data from a randomized
controlled trial “Study on Preventing Adverse Events in Neonates” (SEPREVEN).
Note that disclosure was not intended to be related to the intervention tested
in that study.
Errors in the 10 participating French NICU’s were reported
in the study. The professional who discovered the error used a
self-administered questionnaire created for the study, to report
disclosure/non-disclosure, or gave it to another staff member who might have
been more likely to disclose it. The form covered both the reporter and the
discloser (if any) and their involvement in the process leading to it and also assessed their perception of how the parent(s)
reacted to disclosure.
The analysis included 1822 medical errors in 1019 patients. Of
these, 752 (41.3%) were disclosed to parents. When evaluated by severity
(whether harm occurred or not), errors in the subgroup where harm occurred were
disclosed in 58.7% of events. Harmless errors were disclosed less frequently
than moderate or severe errors (27.7%, 54.8%, and 79.3%, respectively).
When professionals were asked about factors that led to
their disclosing errors, the top 3 responses were by perception of a
professional obligation (63.3%), the error’s visibility (51.7%), and its severe
consequence (27.0%). The top three reasons for non-disclosure were parental absence
at error observation (68.6%), non-severe or unknown consequences (53.8%), and
fear of stressing the parents (34.5%).
Perceived parental reactions were most frequently empathy
towards the professional (34.8%), followed by anxiety (25.3%), resignation
(24.4%), and surprise (11.9%). Mothers’ and fathers’ reactions were similar.
14.1% of reactions were perceived as mixed (negative as well as positive).
Negative reactions (anxiety, resignation, surprise, anger/aggressiveness, or
sadness) were associated with time between NICU admission and error, a severe error,
disclosure by a physician rather than a nurse, and a previous disclosed error
in the NICU for this child.
It was clear to the
authors that the influence of parental involvement was a key factor in the
professionals’ attitudes regarding disclosure. That a weak professional–parent
relationship might be negatively associated with the decision to disclose was
suggested by the finding that non-disclosure was associated with parents’
absence at the error discovery, error discovery at night, and a shorter
interval between NICU admission and the error.
Two of the common reasons for non-disclosure (protecting the
parent from further stress, and fear of undermining trust in the relationship)
may be false assumptions. It is difficult to quantify the impact of parental
stress or anxiety. And, while disclosure of an error can in some cases reduce
trust in the physician-parent relationship, the fact that the perceived
parental response to disclosure was empathy towards the professional in 34.8%
is reassuring. And, when an error comes to the attention of a parent via other
mechanisms, the failure to disclose has a much more negative impact on trust in
the relationship.
Interestingly, fear of the parents’ reaction—aggression, anger,
a lawsuit or demand for compensation—was very rarely
the motive reported for non-disclosure. The authors note that the French legal
system is substantially less litigious than in countries like the US, and provides faster and more certain (although less
generous) compensation in the event of medical errors, without the need for
families to sue healthcare professionals or hospitals.
In an accompanying editorial, Gallagher et al. (Gallagher
2023) note that we often have programs to support clinicians after error
disclosure, m but we need much more attention to understanding what support
patients and families need. They suggest the most important first step is
simply asking the patient and family early and often what can be done to help
them cope with the disclosure and any associated harm, and then striving to
meet these needs. They note many organizations are developing a liaison role
distinct from the clinical team that can support patients and families after
error disclosure. They go on to discuss many elements of Communication and
Resolution Programs (CRP’s) that have been developed to proactively support
patients and families following medical errors.
There are several other important elements to include in
communications with patients, parents, and families that we discussed in our
Patient Safety Tips of the Week for June 22, 2010 “Disclosure
and Apology: How to Do It” and March 9, 2021 “Update: Disclosure and
Apology: How to Do It”. Patients and families
also want to hear that you will be using lessons learned from the event to ensure
similar errors do not occur in the future and impact other patients. One of the
most important points, from our perspective, is letting them know that you will
be having multiple conversations with them, periodically keeping them up to
date with regards to the status of your investigation and RCA (root cause
analysis) and the steps you take to prevent recurrence of such errors. You
also want to let them know about continued care for the patient (assuming it
was not a fatal error), what harm the error may have caused, and how what will
be done about that harm.
The contribution made by Passini
et al. in their study is much welcomed. Despite all
that’s been written and discussed about disclosure, theirs
is the first study we know of to actually show us what
is happening in the real world.
Some of our prior
columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple
Patients”
June 22, 2010 “Disclosure
and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI:
Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
December 17, 2013 “The Second Victim”
July 14, 2015 “NPSF’s RCA2 Guidelines”
June 2016 “Disclosure
and Apology: The CANDOR Toolkit”
August 9, 2016 “More on the Second Victim”
January 3, 2017 “What’s
Happening to “I’m Sorry”?”
October 2017 “More
Support for Disclosure and Apology”
April 2018 “More
Support for Communication and Resolution Programs”
August 13, 2019 “Betsy Lehman Center Report
on Medical Error”
September 2019 “Leapfrog’s
Never Events Policy”
March 9, 2021 “Update: Disclosure and
Apology: How to Do It”
November 2021 “When
a Radiologist Recognizes He Committed an Error”
May 31, 2022 “NHS Serious Incident
Response Framework”
Other very valuable
resources on disclosure and apology:
·
IHI’s “Respectful Management of Serious Clinical
Adverse Events” (Conway
2010)
·
The Canadian Disclosure Guidelines (Canadian
Patient Safety Institute 2008)
·
The Harvard Disclosure Guidelines (Massachusetts
Coalition for the Prevention of Medical Errors 2006)
·
The ACPE Toolkit (American College of
Physician Executives)
·
Oregon Patient Safety Commission Oregon
Adverse Event Disclosure Guide.
References:
Passini L, Le Bouedec
S, Dassieu G, et al. Error disclosure in neonatal
intensive care: a multicentre, prospective,
observational study. BMJ Quality & Safety 2023; Published Online First: 14
March 2023
https://qualitysafety.bmj.com/content/early/2023/03/13/bmjqs-2022-015247
Gallagher TH, Hemmelgarn C,
Benjamin EM. Disclosing medical errors: prioritising
the needs of patients and families. BMJ Quality & Safety 2023; Published
Online First: 19 June 2023
https://qualitysafety.bmj.com/content/early/2023/06/18/bmjqs-2022-015880?rss=1
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