1 Dealing with Medical Errors What should I say? R Singh MB BChir MA (Cantab) MBA MD (SUNY) Department of Family Medicine Associate Professor and Associate Director, UB Patient Safety Research Center Presented in 2010 by gurdev Singh, Director, UB Patient Safety research Center Patient Safety Research Center
2 Dealing with Medical Errors What should I say? R Singh MB BChir MA (Cantab) MBA MD (SUNY) Department of Family Medicine Associate Professor and Associate Director, UB Patient Safety Research Center Health Warning: This talk may raise more questions than it answers!! Presented in 2010 by gurdev Singh, Director, UB Patient Safety research Center Patient Safety Research Center
3 The Six ACGME Core Competencies Communication Knowledge Professionalism Patient Care Practice Based Learning System Based Practice Safety Transcends all Competencies Singh 07
4 Safety is a fundamental system property. Without safety there can be no quality of care IOM Patient Safety Is freedom from accidental injury due to medical care or medical error Gurdev Singh 2007
5 National Burden of Systemic Errors in the Health Care The(US) TheUS Healthcare 2-5 Jumbo jets of the Health Care Industry drop out of the sky every day (Analogy after Leape: the Safety Guru of USA) 1.5 Million/year Incidents of Harm And then there are other adverse Events!! Gurdev Singh 2007 Singh 07
6 International Rankings and National Health Expenditure (Through Patient s Lens) AUS CAN GER NZ UK USA Overall Ranking Patient Safety Effectiveness ? Patient-centeredness Timeliness Efficiency Equity Health Expend./Capita $ $5,635 $7600 Source: The Commonwealth Fund : Singh 07
7 Our Goal Congressional Budget Office Head, Peter Orszag: Times Nov 08 Singh 08
8 Our Goal If this is not a MAJOR National Disaster my name is not gurdev Congressional Budget Office Head, Peter Orszag: Times Nov 08 Singh 08
9 Singh 07 Singh: Jan 09
10 Singh 07 This constitutes nearly 50% of the surgical Never Events Wrong body part : 30% Wrong procedure : 16% Wrong patient: 4% COST About 20Billion/yr CMS press release 2006 (Minnesota Study) Singh: Jan 09
11 Patient Safety Awareness Week March 7-13 March 7-13
12 Currently we live in Fear R and G Singh Scherkenbach s Cycle of Fear, 1991
13 Currently we live in Fear Kill the messenger (denial; shift the blame) R and G Singh Scherkenbach s Cycle of Fear, 1991
14 Currently we live in Fear Kill the messenger (denial; shift the blame) Filter the data (game the system) R and G Singh Scherkenbach s Cycle of Fear, 1991
15 Currently we live in Fear Micromanage (Barking up the wrong tree) Kill the messenger (denial; shift the blame) Filter the data (game the system) R and G Singh Scherkenbach s Cycle of Fear, 1991
16 Currently we live in Fear Micromanage (Barking up the wrong tree) Kill the messenger (denial; shift the blame) Filter the data (game the system) R and G Singh Scherkenbach s Cycle of Fear, 1991
17 From January to May, I work for the government to pay for my income tax and from May to October to pay for my malpractice insurance Singh
18 There are increasing calls for Error Disclosure from various directions with increasing disclosure protection Singh
19 Overview Background Current culture of blame and non-disclosure Ideal culture of safety with open disclosure Ethical principles What do patients want? What do physicians think? Risks and Benefits of Disclosure A practical approach to disclosure Conclusions
20 Background1/3 Errors are common Harm sometimes occurs it is preventable System problems are usually at the root Humans are often unfairly blamed To err is human Current culture is conducive to hiding errors to avoid repercussions When errors are hidden we cannot learn from them
21 Example: System for ordering labs and obtaining results (a small sub-system!) Doctor Test Log Doctor s In-Box Lab Slip Lab Report Clerk Doctor Patient To be filed Patient Specimen collection Chart
22 Background2/3 When errors are hidden we cannot learn from them We need to change the culture!! In a Culture of Safety: Micromanage (Barking up the wrong tree) Fear Filter the data (game the system) Kill the messenger (denial; shift the blame) Scherkenbach s Cycle of Fear, 1991 People are able to discuss errors openly without fear of repercussions Attention is focused on faulty systems rather than blaming individuals for all problems This includes disclosing errors to patients and families where appropriate R and G Singh Currently we live in
23 Background3/3 Disclosing errors to patients and families How can we decide whether it is appropriate to disclose or not?
24 Ethical Principles that can guide our disclosure decisions *Beneficence act in the best interests of the patient *Nonmaleficence - do no harm *Patient Autonomy protect and foster a patient's free, uncoerced choices *Justice fairness of healthcare in society
25 If it s often the right thing to do why not just do it?
27 From January to May, I work for the government to pay for my income tax and from May to October to pay for my malpractice insurance Singh
28 What do patients want?1/3 Gallagher et al JAMA (8) Patients wanted disclosure of all harmful errors and information about: *What happened *Why the error happened *How the error's consequences will be mitigated *How recurrences will be prevented. NOTE: they don t want to know who s fault it is Patients also desired emotional support, saying that they would be less upset if the physician: *Talked honestly *Showed compassion *Apologized Qualitative study (13 focus groups of patients/physicians)
29 What do patients want?2/ Schwappach Int J Qual H Care (4): Internet survey 1017 citizens of Germany In cases with a severe outcome, if the physician was: Honest Empathic Accountable Then, there was a 59% decrease in support for strong sanctions (e.g., lawsuits) against the physician
30 What do patients want?3/3 Witman et al Arch Int Med : outpatients at an academic medicine clinic 98% wanted to be informed, even of a minor error For errors of various severities, patients reported that if they were informed of the error by the physician (vs. finding out from another source) then they were: Error of Moderate Severity Less likely to change doctors (60 vs. 92%) Less likely to report the physician (23 vs. 52%) Less likely to file a lawsuit (12 vs. 20%)
31 Why do people sue?1/2 Of course, every case is different. Studies have shown that there is little, if any, correlation between quality of care and likelihood of malpractice claims. Many suits are filed even when no lapse in quality has take place. In cases where medical negligence has taken place, only a small minority of patients or families file suit (perhaps as low as 3%) So, why do people sue??
32 Why do people sue?2/2 Hickson et al JAMA 1992;268(11): Interviewed 127 mothers who had sued due to perinatal injuries to their infants. Reasons for filing suit included: Advised to sue by knowledgeable acquaintance (33%) Recognized a cover-up (24%) Needed money (24%) Needed information (20%) Wanted to protect others from harm (19%) Respondents believed that their physician(s): Tried to mislead them (48%) Did not talk openly (32%) Did not listen (13%)
33 What do physicians think? Gallagher et al JAMA (8) Qualitative Study Physicians agreed that harmful errors should be disclosed but "choose their words carefully" when telling patients about errors. often avoided stating that an error occurred, why the error happened, or how recurrences would be prevented. Physicians were upset when errors occurred and expressed a desire to apologize but worried that an apology might create legal liability.
34 Benefits and Risks of Disclosure1/2 Benefits to the Patient *Opportunity to receive corrective treatment *Helps them to make informed decisions *Promotes trust in the physician *Alleviates worry why did that happen to me? *Acknowledges fallibility encourages patient to take greater responsibility for their own care *Opportunity to receive fair compensation Benefits to the Physician May be less likely to be sued *If sued, the fact that you disclosed may help your case *May help alleviate stress *Fulfills your moral obligation to tell the truth
35 Benefits and Risks of Disclosure2/2 Risks to the Patient Anxiety / Confusion (but pt s in Gallagher s study did not report this) Loss of trust in the system These risks may justify non-disclosure of inconsequential errors Risks to the Physician Risk of being sued (if the patient wouldn t otherwise know about the error) Risk of disciplinary action Possible loss of reputation Loss of patients
36 Joint Commission Requirement (Endorsed by most Patient Safety and Risk Management organizations) As a requirement of Joint Commission certification, hospitals must develop policies on disclosure of unanticipated outcomes to patients/families. Disclosure only required for unanticipated outcomes ie when there is harm Don t have to disclose an error if no harm results But: Does this meet the ethical standard? Who is to decide what harm is?...
37 Was there harm? Differing perceptions of harm. Is it harm if Treatment is delayed slightly? Hospital stay is prolonged? Patient undergoes unnecessary tests? Patient has to incur additional costs? Hospital or health plan has to incur additional costs? Harm may not be apparent until after discharge. Therefore the patient may need to be informed of warning signs for potential harm. These and other practical issues need to be resolved
38 What should I say? As a student do nothing by yourself! If you discover an error: Inform your supervisor(s) Discuss possible disclosure options Ultimately the physician has to decide whether to disclose and what to say
39 What should I say? As a physician If no or mild harm Consider informing (weigh the risks and benefits) If significant harm Consult with risk management / malpractice carrier Consider informing (weigh the risks and benefits) If you decide to disclose: What should you say?
42 Error disclosure protocol:1/6 Consider doing the following (in a timely fashion): (after weighing up the risks and benefits) 1. Acknowledge the error 2. Apologize and empathize 3. Accept some responsibility 4. Commit to investigate & prevent 5. Set the tone 6. Address adverse consequences 7. Address any other concerns 8. Arrange follow-up
43 Error disclosure protocol:2/6 1. Set the tone in person eye-level private & respectful consider participants check comfort allow time for the patient/family to react to what you say listen
44 Error disclosure protocol:3/6 2. Acknowledge the error Be direct Use words such as error or mistake I think you received the wrong medication by mistake You are right - you were supposed to get the MRI today. Sounds like an error was made.
45 Error disclosure protocol:4/6 3. Apologize and empathize I m sorry that this happened to you is not an admission of guilt it s not a true apology either! I certainly understand your anger about the unnecessary delay in your discharge an expression of empathy I m sorry I made a mistake is a true apology however, it is an admission of guilt may create legal liability in some states may be premature (most harm is multi-factorial and involves system failures)
46 Error disclosure protocol:5/6 4. Accept some responsibility for the error and its consequences If you are sure it was your error, consider saying so: It was my mistake. I forgotten to write the order. [Note that this can create legal liability] If it is possible you may have contributed to the error, consider saying so: I m not sure how this happened. I may have written the wrong order, or maybe it was illegible, or maybe someone else made a mistake in following the orders. Don t be too sure about your personal responsibility without some pause for reflection and supervision. Guilt can influence your words.
47 Error disclosure protocol:6/6 5. Commit to investigate and prevent Commit to investigate the error to find its causes Commit to inform the patient of the findings Commit to attempt to prevent the error from happening again 6. Address adverse consequences Screen & work up as needed Educate/advise patient as needed 7. Address any other concerns 8. Arrange Follow-up
48 Tips for safe disclosure Don t t be evasive *Make yourself available *Don t t say No comment Don t t jump to conclusions prematurely some questions require further investigation before they can be answered. Say that you are not sure rather than blaming someone else or denying responsibility immediately. Don t t use jargon the patient may think you are trying to confuse them. Don t t promise something unless you can deliver.
49 Conclusions - Theory Ethical arguments in favor of full and honest disclosure of all errors, regardless of harm caused, are widely recognized. JC requires that errors be disclosed if harm occurs. Most patients desire full disclosure and an apology. Fear of litigation makes many physicians feel uncomfortable disclosing information and apologizing. The desire to find out what happened, and to prevent recurrence are the cause of many lawsuits. Disclosure may decrease the risk of litigation since it helps to meet these needs further studies are needed.
50 Conclusions - Practice Don t despair (it s not all doom and gloom!) Most errors have relatively mild effects as a physician, errors will happen in your practice but you can manage them effectively if you communicate well with your patients For errors that cause serious harm you are not alone help is available
51 Final Thought Treat other people the way you would want to be treated.
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