We’ve done several columns promoting disclosure and apology after medical errors as being the right thing to do. One of the “gray zones” has always been in deciding which errors to disclose and whether to disclose errors in which no harm came to patients. An excellent paper (Chamberlain 2012) appeared last month in the surgery literature about disclosure of “nonharmful” medical errors and other events. We all have a tendency not to disclose “near-misses” to patients. But the Chamberlain article rightly points out that determination of “harm” is not a straightforward issue. What may not seem to have caused harm currently may, in fact, lead to harm in the future. The article discusses the ethical issues involved and advocates for taking view from the patient’s perspective. Research shows that most patients want to be made aware of mistakes and potential mistakes and that such disclosure usually improves the patient/physician relationship. Moreover, physicians who disclose the error to the patient/family are also then likely to report the error to the organization, perhaps leading to lessons learned that can help prevent future occurrences that might cause harm.
The article then has several practical recommendations about how to disclose medical errors to patients:
· Disclosure should be done in a timely fashion and delivered in a clear, concise manner using language that the patient can clearly understand.
· The patient should have adequate opportunity to ask questions and get clarification.
· The potential outcomes and long-term consequences should be discussed.
· It should be explained that the surgeon and medical team will be monitoring the patient for potential complications.
· All this should be done with an apology and it should be noted the error/event will be reported to the medical institution in hope that future similar errors/events will be prevented.
We, of course, advocate that the apology should really be the initial part of the discussion. It sets the tone for the remainder of the discussion and is critical in maintaining trust in the physician/patient relationship.
The article also notes that informed consent done before surgery also sets the tone for any subsequent disclosure. Informed consent should provide the patient with both the potential benefits and risks of surgery and a discussion of what would ensure if any of the risks came to pass.
But in reality there is a gap between the intent a physician has regarding error disclosure and the actual act of disclosure. A new paper (Ghalandarpoorattar 2012) reported the results of a survey given to surgical attendings and residents. Two error scenarios were presented, one a relatively minor one and the other major, and respondents were asked a series of questions about their attitude toward disclosure and their actual practices. Though the study was done in Iran we suspect that the results would probably not differ a whole lot if the survey were given in multiple sites in the US. About half said they would disclose the error in the major scenario and about 40% in the minor scenario, though almost 2/3 would disclose if asked by the patient about the event. Over half admitted they had made mistakes in the past year but only 16.7% had disclosed that error to the patient. The four top barriers to disclosure were: (1) fear of malpractice lawsuit (2) fear of loss of the patient’s trust (3) fear of the patient’s family members’ emotional response and (4) fear of losing professional fame among colleagues. And despite the fact that the literature suggests that disclosure and apology mitigate at least the first three outcomes, very few of the respondents actually believed what the literature says. Interestingly, those that did do disclosure were very satisfied with doing so, even those that eventually were involved in litigation.
Interestingly, in a survey of clinical pathologists and laboratory directors in the US (Dintzis 2011) results were strikingly similar (See our March 6, 2012 Patient Safety Tip of the Week ““Lab” Error”). Despite widespread support for reporting errors via hospital error reporting mechanisms, only 16.2% ever disclosed a serious error to a patient. But rather than being deterred by fear of malpractice suits, their main barriers to disclosure were thoughts that the patient would not understand what he/she was being told or that the physician would not be able to explain clearly. Nevertheless, those that were involved in direct disclosure to patients were highly satisfied with the experience.
Obviously we need to do a better job making it easier for all physicians to “do the right thing” and do disclosure and apology in an honest and caring way.
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “ ”
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)
Chamberlain CJ, Koniaris LG, Wu AW, Pawlik TM. Disclosure of "Nonharmful" Medical Errors and Other Events. Duty to Disclose. Arch Surg. 2012; 147(3): 282-286
Ghalandarpoorattar SM, Kaviani A, Asghari F. Medical error disclosure: the gap between attitude and practice. Postgrad Med J 2012; 88: 130-133
Dintzis SM, Stetsenko GY, Sitlani CM, et al. Communicating Pathology and Laboratory Errors. AJCP 2011 135:760-765
Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events. IHI Innovations Series 2010. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2010
Canadian Patient Safety Institute. Canadian Disclosure Guidelines. May 2008
Massachusetts Coalition for the Prevention of Medical Errors. When Things Go Wrong. Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. 2006
The American College of Physician Executives. Disclosure and Apology Toolkit.