Disclosure of medical errors: The right thing to do - JAAPA

Disclosure of medical errors: The right thing to do
From QCC, the Quality Care Committee of the AAPA
August 18, 2010

Imagine for a minute that you practice in radiology. Your primary role over the past 10 years has been to work with an interprofessional team in providing care at a well known comprehensive breast care center. You are helping to interpret a diagnostic mammogram that shows a large malignant lesion in a 41-year-old woman. Both you and the radiologist are surprised at the finding because a screening mammogram obtained just 6 months earlier was positive only for "small calcifications." After a brief inspection of past office visit records and mammograms, you realize, to your shock, that a mistake was made in the prior interpretation of the patient's screening mammograms. A systems error is revealed that allowed the prior films to be reviewed in reverse order showing a "decrease in the number of calcifications" when the calcifications were actually increasing in size and number. How likely would you be to disclose this error to the patient?


HUMANS ARE FALLIBLE


Medical mistakes occur as a result of human fallibility compounded by poor system designs in health care that allow for error. Furthermore, these mistakes are rarely the result of personal negligence or criminal activity. Medical mistakes can have devastating emotional and physical consequences for both the patient and the health care provider. The past decade has seen an extensive body of research develop around the core topics of patient safety and medical errors resulting in unintentional harm. Medical mistakes in the United States cause unintentional death in nearly 100,000 people annually, which means that medical mistakes rank as the 8th most common cause of death.1


The opening clinical vignette was part of a research study published in the November 2009 issue of the journal Radiology.2 Of the 364 radiologists who read the vignette and responded to survey questions about it, 10% answered that they would "definitely not" disclose the error to the patient, 51% would disclose the error "only if asked by the patient," 26% answered "probably," and 14% responded "definitely." These results illustrate some of the key challenges surrounding the disclosure of medical errors. Even though we are called by duty to do no harm and we know that truth-telling is the moral and ethical standard we live and work by, health care providers continue to be reluctant to disclose mistakes. The fictitious vignette involves a mishap in radiology, but mistakes happen regularly in all areas of health care. This article explores why disclosure of medical errors takes place or does not take place when misadventures in care delivery occur and reviews the evolving science around the importance of disclosure.


THE SCIENCE OF DISCLOSURE


Recent studies on disclosure have focused on the physical, emotional, legal, and financial significance of acknowl­edging medical mistakes to patients once they occur. The Joint Commission has accreditation standards in place that require health care providers to inform patients about "unanticipated outcomes." In 2006, the National Quality Forum (NQF) added disclosure of adverse events to its manual on safe practices. Recognition by organizations such as the Joint Commission and NQF underscores the important contribution that the science of disclosure has made, especially over the past two decades.


As disclosure science in health care continues to progress, much of the data generated highlights the fundamental importance of openly admitting error.3 A number of these studies suggest that both the public and health care professionals generally agree that medical errors causing harm should be disclosed to the patient. One seminal publication found that of 149 respondents made up of randomly selected patients in an academic internal medicine practice, roughly 98% responded that even minor errors should be acknowledged by their physician.4 Not surprisingly, the same study showed that patients were significantly more likely to consider litigation if the error was not disclosed to them. 


"Deny and defend" has historically been the defense mechanism utilized by providers who have caused unintended medical harm. Studies have shown that this response to a medical error does not meet the emotional needs of the patient,5 but the response often does not meet the emotional or professional needs of the clinician either. Nevertheless, one reason why clinicians may react this way is the anxiety or fear they feel as a result of harming a patient unintentionally. Aside from the personal anguish and shame clinicians shoulder after having made a mistake that caused harm, fear of professional embarrassment and fear that the patient will take legal action against the provider are chief concerns.


Lucian Leape, a world renowned expert on patient safety, explains that "fear arises from the belief that errors and mishaps are caused by carelessness for which the responsible individual should be punished. Doctors and nurses have been taught to believe this, so they fear both making a mistake and being caught. They and the public are quick to blame individuals when they make errors."6 Neither "shame and blame" of clinicians involved in medical errors nor "deny and defend" are effective strategies for reducing the emotional or psychological impact of errors, nor do they contribute to improved reporting and prevention of future errors.

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Disclosure of medical errors: The right thing to do - JAAPA

related article;
http://www.nytimes.com/2010/08/19/health/19chen.html?_r=1