AHRQ Patient Safety Network - Error Disclosure

AHRQ Patient Safety Network - Error Disclosure

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Error Disclosure

Background

Many patients harmed by a medical error never learn of the error. Physicians have traditionally shied away from discussing errors with patients, in part due to fear of precipitating a malpractice lawsuit, but also due to embarrassment and discomfort with the disclosure process. However, attitudes have changed in recent years—most physicians in a 2006 survey had disclosed a serious error to a patient and agreed that such disclosure was warranted.

Surveys have helped to define the components of disclosure that matter most to patients. These include:

• Disclosure of all harmful errors
• An explanation as to why the error occurred
• How the error's effects will be minimized
• Steps the physician (and organization) will take to prevent recurrences

"Full disclosure" of an error incorporates these components as well as acknowledgement of responsibility and an apology by the physician. However, there may be a disconnect between physicians' views of ideal practice and what actually happens. For example, most physicians agree that errors should be fully disclosed to patients, but in practice many "choose their words carefully" by failing to clearly explain the error and its effects on the patient's health.

Source: Gallagher TH, Garbutt JM, Waterman AD, et al. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Intern Med. 2006;166:1585-1593. [go to PubMed]

Accomplishing Full Disclosure

Increasing the amount and quality of error disclosure will require addressing physician discomfort with disclosure and fear of lawsuits. This may also require changes in how organizations approach error disclosure. Clinicians' fear regarding legal repercussions of error disclosure is not entirely unfounded, as a clinician's disclosure of an error may be admissible in a malpractice lawsuit. According to a 2008 survey, only eight states in the US explicitly prohibited "admissions of fault" from being used as evidence at trial (although the majority of states exclude "expressions of sympathy" from being admissible evidence). However, data does indicate that patients are less likely to consider filing suit if physicians apologize and fully disclose errors. Low disclosure rates also persist because few physicians have received formal training in how to discuss errors with patients, and given that the circumstances surrounding an error are invariably complex, physicians may be unclear about the amount of information that should be disclosed and how to explain the error to the patient. There is some evidence that formal training in error disclosure can improve physicians' comfort with the process.

When a patient is a victim of an error, hospitals have traditionally followed a "deny-and-defend" strategy, providing limited information to the patient and family and avoiding admissions of fault. This response has been criticized for its lack of patient-centeredness, and in response, some institutions have begun to implement "communication-and-response" strategies that emphasize early disclosure of adverse events and a more proactive approach to achieving an amicable resolution. The University of Michigan model—which includes full disclosure of adverse events, appropriate investigations, implementation of systems to avoid recurrences, and rapid apology and financial compensation when care is deemed unreasonable—has resulted in fewer malpractice lawsuits and lower litigation costs since implementation. A growing body of literature describes the regulatory, legal, and practical considerations with implementing these programs. Although communication and resolution programs are being more widely adopted, implementing such a process is quite complex, and several studies indicate that the error disclosure process must be handled thoughtfully and sensitively to avoid alienating patients and families.

Current Context

Disclosure of errors and adverse events is now endorsed by a broad array of organizations. Since 2001, the Joint Commission has required disclosure of unanticipated outcomes of care. In 2006, the National Quality Forumendorsed full disclosure of "serious unanticipated outcomes" as one of its 30 "safe practices" for health care. The disclosure safe practice includes standards for practitioners regarding the key components of disclosure. It also calls for health care organizations to create an environment conducive to disclosure by integrating risk management and patient safety activities and providing training and support for physicians.

As of April 2008, seven states (Nevada, Florida, New Jersey, Pennsylvania, Oregon, Vermont, and California) mandate disclosure of unanticipated outcomes, and 36 states have enacted laws that preclude some or all information contained in a practitioner's apology from being used in a malpractice lawsuit.

STUDY
Nurses' perspectives regarding the disclosure of errors to patients: a qualitative study.
McLennan SR, Diebold M, Rich LE, Elger BS. Int J Nurs Stud. 2014 Oct 9; [Epub ahead of print].

STUDY
Medical harm: patient perceptions and follow-up actions.
Lyu HG, Cooper MA, Mayer-Blackwell B, et al. J Patient Saf. 2014 Nov 13; [Epub ahead of print].

STUDY
Improving healthcare systems' disclosures of large-scale adverse events: a Department of Veterans Affairs leadership, policymaker, research and stakeholder partnership.
Elwy AR, Bokhour BG, Maguire EM, et al. J Gen Intern Med. 2014 Oct 30; [Epub ahead of print].

NEWSPAPER/MAGAZINE ARTICLE
Living with cancer: not talking about medical mistakes.
Gubar S. New York Times. October 30, 2014.

NEWSPAPER/MAGAZINE ARTICLE
Patient- and family-centered care: error disclosure and investigation.
Connor M, Wayman KI, Garcia C, Fischer PR; Consortium for Maximizing Family-Centered Care. Patient Saf Qual Healthc. September/October 2014;11:36,38-40,42.

COMMENTARY
Saying "I'm sorry": error disclosure for ophthalmologists.
Lee BS, Gallagher TH. Am J Ophthalmol. 2014;158:1108-1110.

COMMENTARY
Another surgeon's error: must you tell the patient?
Moffatt-Bruce SD, Denlinger CE, Sade RM. Ann Thorac Surg. 2014;98:396-401.

Tough Call: Addressing Errors From Previous Providers.
William Martinez, MD, MS, and Gerald B. Hickson, MD. AHRQ WebM&M [serial online]. March 2014

Can Research Help Us Improve the Medical Liability System?.
Allen Kachalia, MD, JD. AHRQ WebM&M [serial online]. March 2012

Medication Reconciliation Pitfalls.
Robert J. Weber, PharmD, MS. AHRQ WebM&M [serial online]. February 2010

Disclosure of Medical Error.
Allen Kachalia, MD, JD. AHRQ WebM&M [serial online]. January 2009

In Conversation with…Thomas H. Gallagher, MD.
AHRQ WebM&M [serial online]. January 2009

Removing Insult from Injury—Disclosing Adverse Events.
Albert W. Wu, MD, MPH. AHRQ WebM&M [serial online]. Febuary 2006

The Wrong Shot: Error Disclosure.
Thomas H. Gallagher, MD; Wendy Levinson, MD. AHRQ WebM&M [serial online]. June 2004 

AUDIOVISUAL

When Things Go Wrong: Voices of Patients and Families.
Cambridge, MA: CRICO/RMF; 2006.

BOOK/REPORT

Risk Management Pearls on Disclosure of Adverse Events.
Amori G. Chicago, IL: American Society for Healthcare Risk Management; 2006.

JOURNAL ARTICLE

 Communication-and-resolution programs: the challenges and lessons learned from six early adopters.
Mello MM, Boothman RC, McDonald T, et al. Health Aff (Millwood). 2014;33:20-29.

 Talking with patients about other clinicians' errors.
Gallagher TH, Mello MM, Levinson W, et al. N Engl J Med. 2013;369:1752-1757.

Patients' and family members' views on how clinicians enact and how they should enact incident disclosure: the "100 patient stories" qualitative study.
Iedema R, Allen S, Britton K, et al. BMJ. 2011;343:d4423.

 How does routine disclosure of medical error affect patients' propensity to sue and their assessment of provider quality?: Evidence from survey data.
Helmchen LA, Richards MR, McDonald TB. Med Care. 2010;48:955-961.

 Liability claims and costs before and after implementation of a medical error disclosure program.
Kachalia A, Kaufman SR, Boothman R, et al. Ann Intern Med. 2010;153:213-221.

Narrative review: do state laws make it easier to say "I'm sorry?"
McDonnell WM, Guenther E. Ann Intern Med. 2008;149:811-815.

 The many faces of error disclosure: a common set of elements and a definition.
Fein SP, Hilborne LH, Spiritus EM, et al. J Gen Intern Med. 2007;22:755-761.

 Choosing your words carefully: how physicians would disclose harmful medical errors to patients.
Gallagher TH, Garbutt JM, Waterman AD, et al. Arch Intern Med. 2006;166:1585-1593.

 Does full disclosure of medical errors affect malpractice liability? The jury is still out.
Kachalia A, Shojania KG, Hofer TP, Piotrowski M, Saint S. Jt Comm J Qual Saf. 2003;29:503-511.

 Patients' and physicians' attitudes regarding the disclosure of medical errors.
Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. JAMA. 2003;289:1001-1007.

 To tell the truth: ethical and practical issues in disclosing medical mistakes to patients.
Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP. J Gen Intern Med. 1997;12:770-775.

NEWSPAPER/MAGAZINE ARTICLE

When doctors admit their mistakes.
Chen PW. New York Times. August 19, 2010.

WEB RESOURCE

Sorry Works!
The Sorry Works! Coalition, PO Box 531, Glen Carbon, IL 62034.

Being open: communicating patient safety incidents with patients and their carers.
National Patient Safety Agency.