Now What? How to Disclose a Medical Error

Thursday, September 14, 200612:00 – 1:00 p.m. EDT

Featured Speaker: Anne Matlow, MD, FRCPCMedical Director, Patient SafetyHospital for Sick ChildrenToronto, Canada

Moderator: Marlene R. Miller, MD, MSc, FAAPDirector of Quality and Safety InitiativesJohns Hopkins Children’s CenterBaltimore, Maryland

A story……..

Matt is a 7 year old boy with diabetesAdmitted to hospital ward after

surgery for appendicitis Elevated glucoseInsulin orderedNurse misreads order: 10 fold errorMatt becomes hypoglycemic, seizes,

aspirates and ends up in ICU

OBJECTIVES

Define the term, “disclosure,” and give at least one example of who should disclose a medical error and when disclosure should be performed.

Identify at least one example of ideal disclosure vs. non-ideal disclosure.

Apply two or more strategies to handle disclosure effectively in an ambulatory setting.

FRAMING THE ISSUE

Error: the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim

Serious Error: has potential to cause permanent injury or transient but potentially life threatening harm

Minor Error: does not cause harm or have the potential to do so

Near Miss: could have caused harm but did not reach patient; intercepted

When things go wrong: responding to adverse events. Harvard Hospitals. March 2006. www.ihi.org

FRAMING THE ISSUE

Adverse event: an injury caused by medical management rather than the patient’s underlying disease; = harm, injury, complication.

Preventable adverse event: injury that results from an error or systems failure

When things go wrong: responding to adverse events. Harvard Hospitals. March 2006. www.ihi.org

FRAMING THE ISSUE

DISCLOSURE: Providing information to a

patient and /or family about an adverse event or serious error

= COMMUNICATION

When things go wrong: responding to adverse events. Harvard Hospitals. March 2006. www.ihi.org

WHAT IS THE RIGHT THING TO DO?

MDGuilty

EmbarrassedAfraid

MOMWorriedupset

MATT?

The Essentials of Disclosure

Why disclose?What types of events should be

disclosed?What should be said?Who should disclose?To whom ?When and where should the disclosure

take place?And how should it be done?

Why disclose?

Legal ObligationEthical imperative Right thing to do Respect of patient autonomy: AMA,

CMA: rights of patients to receive all information necessary to make informed and educated decisions about their care

Preserve Patient -physician trust

Why else?PolicyHealing / closure for care giver

“Apologizing might, in fact, be a useful approach to resolving both physician and patient distress after an error.”

Improve safety “The need to tell patients about error’s

cause and prevention could create stronger links between physicians and safety programs, reducing future errors.”

Source: Gallagher, JAMA, Feb 2003

But…………………..

Will I be sued???

Empirical Studies

50% of lawsuits are launched due to suspicion of cover-up or desire for revenge (Hickson JAMA

1992;267:1359)

Almost all lawsuits involve a breakdown of the physician / patient relationship, less than 20% involve negligence (Green AIM 1988; 109:234)

Extreme Honesty May Be the Best Policy Lexington VA Kraman & Hamm, AIM 1999;

131:963

86 % tile

22 % tile

Proactive full disclosure to patients who have been injured

Patients want to know more than what doctors want to tell

Patients have a lower threshold for hearing the details

Parental Preferences for Error Disclosure, Reporting and Legal Action after medical error in the care of their children

ED, non acute illness, 500 participants

4 scenarios, 5 scale Likert response

99% wanted disclosure one third of cases less likely to

seek legal counsel with disclosure

Hobgood Peds 2005;116:1276

What Patients Want When Things Go Wrong

an explicit statement that an error occurred,

to be told what the error was, to be told why the error occurred, to know what will be done to

prevent recurrences, and an apology Gallagher Arch Int Med 2005; 165:

1819.

How would this go over?

Scene takes place at the elevator…. Oh hi, Mrs Jones. Too bad about Matt,

huh? Diabetes is a bad disease and sometimes kids end up in intensive care!!

Or That stupid nurse! She can’t even read! What do they teach them in nursing

school these days anyway?

About Disclosing…

Remember: disclosure is a process, not a “one off”

More information may emerge over time

Take care of the patient now and later

What……..

Acknowledge that the event occurred

Give the facts, in order, simply

Take responsibility and apologize

Commit to finding out why

…….what……..

Explain what impact the event will have on the patient now and in the future

Describe steps being taken to mitigate the effects of the injury

Describe steps being taken to prevent a recurrence

When…

As soon as it is recognized that and the patient is physically and emotionally capable

Ideally within 24 hours after the event is recognized

Make sure the proper people are present Ongoing communication may be

required as more information is available Follow up may be required

Hindsight Bias

Richard Cook

Who Should Disclose?

Health care worker with whom the patient has a trusting relationship

Almost always the responsible physician

Others may be present: eg: nurse, pharmacist, trainee… not too many!

Primary nurse a good idea

To whom?

Parent or substitute decision maker

Patient if capable

Where…

In a quiet and private area Have water and tissues

How…….

Sit down (not on the patient’s bed) Eye level Low, slow voice Be aware of your body language Don’t rush, be patient Be compassionate, remorseful Make sure they’ve understand Do they need anything? Invite further questions now and

later

Basic steps for medical dialogue:

Prepare Initiate conversation Listen actively Acknowledge what you have

heard RespondWhen things go wrong: responding to adverse events. Appendix D. Training for

Communication. Harvard Hospitals. March 2006.

continued……………. Prepare: facts, people, setting Initiate conversation: assess

readiness and comprehension Present facts simply: what we know,

what comes next Apologize Acknowledge and respond Summarize Document: describe the event and

the discussionAdapted from: When things go wrong: responding to adverse events. Appendix

D. Training for Communication. Harvard Hospitals. March 2006.

How about this? Mrs Jones, you’ve had a long day, but I

need to discuss something with you. Matt’s seizure was caused by

hypoglycemia. When he seized he aspirated which is why he is in the ICU.

It looks like he was given too much insulin. We are trying to understand how that happened. When I have more information I will share it with you. I’m so sorry this has happened. Do you have any questions?

……………………….

I understand you are angry. He is on antibiotics and it is likely he

will recover from this pneumonia completely.

Let’s meet again tomorrow and I’ll update you. In the meantime, here is my home phone # in case you think of some questions for later.

Can I get you something before I leave?

in the ambulatory setting………..Why should it be any different?

Another story……..Ashley is an 8 year old girl with

epilepsyRx phenytoin and carbamazepineFirst office visit since hospitalization

for seizures Review of office chart:

subtherapeutic drug levels one week prior to admission to hospital

Report filed before reviewed

The Essentials of Disclosure

Why disclose?What types of events should be

disclosed? What should be said?Who should disclose?To whom ?When and where should the disclosure

take place?And how should it be done?

The Essentials of Disclosure

Why disclose? √What types of events should be disclosed?

√What should be said? √Who should disclose? √To whom ? Make sure the right person thereWhen and where should the disclosure take

place? May need extra time…..And how should it be done? √

OBJECTIVES

Define the term, “disclosure,” and give at least one example of who should disclose a medical error and when disclosure should be performed.

Identify at least one example of ideal disclosure vs. non-ideal disclosure.

Apply two or more strategies to handle disclosure effectively in an ambulatory setting.

In closing……………….

All expression of truth does at length take this deep ethical form.

Henry David Thoreau