We thought we were done doing columns about disclosure and
apology following medical errors. Most hospitals seem to have come on board and
recognize that transparency and honesty, when accompanied by sincere apology,
are the right things to do following medical errors.
But what about physicians? Are they also on board?
A recent survey with
two hypothetical vignettes was presented to primary care physicians (Mazor
2016). The first involved a delayed
diagnosis of breast cancer. The second involved a care coordination breakdown
causing a delayed response to patient symptoms. In both cases, multiple
physicians shared responsibility for the error, and both involved oncology
diagnoses. A majority of respondents would not fully disclose the errors in
either situation. Things that predicted intent to disclose were perceived
personal responsibility, perceived seriousness of the event and perceived value
of patient-centered communication.
A 2016 survey done by Medscape also shows a disturbing trend
(Lowes 2016). 78% of
respondents to the Medscape survey said that it is never okay to cover up or
avoid revealing such an error. Sounds pretty good. However, the percentage who
answered that way was down from 91% in 2014 and almost 95% in 2010. To be fair,
only 7% actually answered “yes” (yes, it is okay to cover up or avoid revealing
an error) and the other 14% said “it depends”. But the direction of the trend
is bothersome. Here’s the link to the
full Medscape
Ethics Report 2016 (Reese 2016).
In our August 9,
2016 Patient Safety Tip of the Week “More
on the Second Victim” we discussed a study of how surgeons address
adverse clinical events with their patients and/or patient families (Elwy 2016).
Elwy and colleagues surveyed surgeons in the Veterans Affairs medical system
about their experiences in disclosing adverse events. Most of the respondents
to the survey used 5 of 8 recommended disclosure items:
But use of the other 3 recommended disclosure items was less
frequent:
They found that surgeons who reported they were less likely
to discuss preventability of the adverse event, those who stated the event was
very or extremely serious, or who reported difficult communication experiences
were more negatively affected by disclosure than others. Those surgeons with
more negative attitudes about disclosure at baseline reported more anxiety
about patients’ surgical outcomes or events following disclosure. The study
clearly highlights the need for training for disclosure and apology and
development of skillsets to use for such. Logically, it might be anticipated
that development of those skills might reduce the negative experiences with
disclosure and apology on the part of surgeons and perhaps be a first step in
aiding the “second victims”, too.
The American Academy of Pediatrics just released a policy
statement “Disclosure of Adverse Events in Pediatrics” (AAP 2016).
It notes that physicians and residents are in agreement that it is an ethical
obligation to their patients to disclose preventable adverse events but that,
in practice, this is not often done. It notes that in an anonymous survey among
pediatric residents and attending pediatricians (Garbutt
2007), pediatricians in private practice were less likely to report errors
than other attending pediatricians (72% vs 92%) and that most attendings and residents agreed that disclosing a serious
error would be difficult. It also showed that residents were more likely than
attending pediatricians to have received education about how to disclose errors
(57% vs 29%). The new AAP policy statement discusses the barriers to disclosure
and legal issues and ways to facilitate better disclosure. It emphasizes the
need for education and training in disclosure skills, including use of
simulation in such training.
Very timely is a Health Services Research theme issue (Ridgely
2016) that deals with communication-and-resolution programs. While you’ll
find multiple articles of interest in that issue, you’ll probably most appreciate
the one by Lambert et al. (Lambert
2016). They implemented their own version of a communication and optimal
resolution (CANDOR) program, which they named the “Seven Pillars” program, at
the University of Illinois Hospital and Health Sciences System. We discussed
CANDOR in our June 2016 What's New in the Patient Safety World column “Disclosure
and Apology: The CANDOR Toolkit”. The 7 pillars are:
(1)
incident reporting
(2)
investigation while holding hospital bills and
professional fees
(3)
early communication with patient/family
(4)
full disclosure, apology, and rapid remedy if
appropriate
(5)
system improvement
(6)
data tracking and evaluation
(7)
education and training
Using an interrupted time series analysis, they were able to
show the program was associated with increases in the frequency of incident
reports, event analyses, and post-event communication consults, and reductions
in claims, legal fees, legal expenses, costs per claim, settlement costs, and
self-insurance costs. Their results were both clinically and financially
significant and persisted for more than 7 years after the initial intervention.
Annual contributions to their self-insurance fund declined dramatically, and
the self-insurance fund moved from a $30 million deficit to a $40 million
surplus. Those results are reassuring and in keeping with the promise seen
after the original University of Michigan success that we described in our September 2010 What's
New in the Patient Safety World column “Followup
to Our Disclosure and Apology Tip of the Week”.
Meanwhile, results from a demonstration project in New York
City were less impressive (Mello 2016a). The
communication-and-resolution program implemented in surgical departments of 5
NYC acute care hospitals was quite successful in handling events not caused by
substandard care, but less consistent in offering compensation in cases
involving substandard care. But one striking finding in that study was that
clinician awareness of the communication-and-resolution program was quite low
and many felt the program did not likely help avoid a lawsuit. The authors felt
that, in those cases where there were violations of standard of care, there was
difficulty adhering to the principle that compensation should be proactively
offered.
Some of the other papers in the theme issue describe some of
the challenges and barriers in establishing disclosure and apology or CANDOR
programs. A study of a communication-and-resolution program (CRP) involving six
hospitals and clinics and a liability insurer in Washington State (Mello 2016b) found that
sites experienced small victories in resolving particular cases and
streamlining some working relationships, but they were unable to successfully
implement a collaborative CRP. Barriers included the insurer's distance from
the point of care, passive rather than active support from top leaders,
coordinating across departments and organizations, workload, nonparticipation
by some physicians, and overcoming distrust.
Two very important parts of any CANDOR program are (1)
understanding the perspective of patients/families following adverse events
that impact them and (2) training healthcare professionals on how to do
disclosure and apology with those patients and families. Gallagher and
colleagues used a patient-created simulation exercise to help accomplish both (Gallagher 2016). Their
experience showed that many stakeholders felt that the current responses to
adverse events were complex, siloed, and
uncoordinated and thus failed to meet the needs of patients and families.
Participants suggested creating a patient navigator-like role to help support
the patient/family throughout the process. They also found that the interest of
the patient/family might not be the top priority for many stakeholders. They
note that risk managers and defense attorneys care
about patients and families but their primary role is to protect the
institution or providers and that plaintiff attorneys and Boards of Medicine
may serve as structural barriers that hamper CANDOR programs. Experiencing how
a patient felt in reading a hospital’s response to her complaint about a
delayed cancer diagnosis elicited both intellectual and visceral responses in
many stakeholders. And patient advocates were impressed by the desire of
stakeholders to better understand the patient/family perspective and improve
the response to adverse events. The article has good recommendations on using
this type of simulation exercise in other organizations.
Another study provided very interesting insights regarding
the involvement of patients and families in investigating adverse events (Etchegaray
2016). We’ve always said that the patient perspective should be
important and have sought ways to involve patients/families in such
investigations. However, we’ve had a hard time figuring out how to do so and
have met resistance from both clinicians and administrators. But the Etchegaray study is a real eye opener. They recruited
patients and families (roughly 50% for each group) who had been involved in an
adverse patient event and did semi-structured interviews with them.
All the participants identified at least one factor
contributing to the adverse event that they or their family member had
suffered. In fact, the average number of contributing factors identified was
3.67 factors. The most common categories of contributing factors noted were
staff qualifications/knowledge (such as unfamiliarity with a drug) identified
in 79%, safety policy/procedures (such as failure to adhere to hand hygiene)
identified in 74%, and communication identified in 64%. While there were a
variety of ways such factors were identified, a full third were identified by
direct observation and, in some cases, would not likely have been identified by
others during a root cause analysis (RCA). And some of the “human” factors they
identified as contributing will surprise you! Those included things like greed,
anger, and one-upsmanship, factors that almost
certainly would not have been revealed during our traditional RCA’s.
Yes, there was likely some degree of selection bias in the
results in that the participants voluntarily agreed to participate and many
were involved in patient safety advocacy groups. They also clearly wanted to
foster learning from their events to help others. But the findings have merit
regardless of any selection bias.
We understand the reluctance of many healthcare
professionals and administrators to have patients or families sit in on a
formal RCA meeting. However, we think that when disclosure and apology are
offered to a patient or family, that is an appropriate time to also seek their
input and perspective. You need to let them know that an investigation will be
done to identify issues that can be corrected to prevent future similar events
and that any observations they may have had will be helpful in that regard. We
usually recommend that the physician do the disclosure/apology and let them
know that a member of the RCA team will meet with them to get their input. That
both gives them time to think about their direct observations and reinforces
that we are committed to improve care and we truly respect their input into the
process.
Levinson et al. recently presented a good practical discussion
of what to do after a medical incident and how to handle disclosure and apology
(Levinson
2016).
Not to be lost in the successes reported at the University
of Illinois in the Lambert study is that they also included peer support in a
“care-for-the-caregiver” program for professionals involved in serious
incidents (see our Patient Safety Tips of the Week for December 17, 2013 “The
Second Victim” and August 9, 2016 “More
on the Second Victim”). In the latter column we noted Carolyn
Clancy’s editorial (Clancy
2012) which suggested the evolving practice of disclosure and apology might
be a means of alleviating the emotional trauma of both the first and second
victims of patient safety events.
The case for disclosure-and-apology and
communication-and-resolution programs is growing. Not only is such transparency
the right thing to do but in the long run is likely mutually beneficial and
leads to future improvements in patient care.
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”
Other very valuable
resources on disclosure and apology:
References:
Mazor K, Roblin DW, Greene SM, et
al. Primary care physicians’ willingness to disclose oncology errors involving
multiple providers to patients. BMJ Qual Saf 2016; 25: 787-795
http://qualitysafety.bmj.com/content/25/10/787.abstract?sid=bf40c687-a54c-4669-9b9c-f68ae6dc99e6
Lowes R. More Physicians Willing to Hide Mistakes, Survey
Reveals. Medscape Medical News 2016; December 01, 2016
http://www.medscape.com/viewarticle/872660
Reese S. Medscape Ethics Report 2016: Money, Romance, and
Patients. Medscape 2016; December 1, 2016
http://www.medscape.com/features/slideshow/ethics2016-part1
Elwy AR, Itani KMF, Bokhour BG, et al. Surgeons’ Disclosures of Clinical
Adverse Events. JAMA Surg 2016; 151(11): 1015-1021
http://jamanetwork.com/journals/jamasurgery/article-abstract/2534133
AAP (American Academy of Pediatrics). Policy Statement. Disclosure
of Adverse Events in Pediatrics. Committee on Medical Liability and Risk
Management, Council on Quality Improvement and Patient Safety. Pediatrics 2016;
138(6): e20163215
http://pediatrics.aappublications.org/content/138/6/e20163215
Garbutt J, Brownstein DR, Klein EJ, et al. Reporting
and disclosing medical errors: pediatricians’ attitudes and behaviors. Arch Pediatr Adolesc Med 2007; 161(2): 179-185
http://jamanetwork.com/journals/jamapediatrics/fullarticle/569612
Ridgely MS, Greenberg MD, Clancy CM (eds.).
Special Issue: Progress at the Intersection of Patient Safety and Medical
Liability. Health Services Research 2016; 51(Suppl S3):
2395-2648 December 2016
http://onlinelibrary.wiley.com/doi/10.1111/hesr.2016.51.issue-S3/issuetoc
Lambert BL, Centomani NM, Smith
KM, et al. The “Seven Pillars” Response to Patient Safety Incidents: Effects on
Medical Liability Processes and Outcomes. Health Services Research 2016; 51(Suppl S3): 2491-2515 December 2016
http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12548/full
Mello MM, Armstrong SJ, Greenberg Y, McCotter
PI, Gallagher TH. Challenges of Implementing a Communication-and-Resolution
Program Where Multiple Organizations Must Cooperate. Health Services Research
2016; 51(Suppl S3): 2550-2568 December 2016
https://www.ncbi.nlm.nih.gov/pubmed/27807858
Mello MM, Greenberg Y, Senecal SK,
Cohn JS. Case Outcomes in a Communication-and-Resolution Program in New York
Hospitals. Health Services Research 2016; 51(Suppl S3):
2583-2599 December 2016
https://www.ncbi.nlm.nih.gov/pubmed/27781266
Gallagher TH, Etchegaray JM, Bergstedt B, et al. Improving Communication and Resolution
Following Adverse Events Using a Patient-Created Simulation Exercise. Health
Services Research 2016; 51(Suppl S3): 2537-2549
December 2016
https://www.ncbi.nlm.nih.gov/pubmed/27790708
Etchegaray JM, Ottosen
MJ, Aigbe A, et al. Patients as Partners in Learning
from Unexpected Events. Health Services Research 2016; 51(Suppl
S3): 2600-2614 December 2016
http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12593/full
Levinson W, Yeung J, Ginsburg S. Disclosure of Medical Error.
JAMA 2016; 316(7): 764-765
http://jamanetwork.com/journals/jama/article-abstract/2544645
Clancy CM. Alleviating “Second Victim” Syndrome: How We
Should Handle Patient Harm. Journal of Nursing Care Quality 2012; 27(1): 1-5,
January/March 2012
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