Since the release of the Institue of Medicine report To Err Is Human in 1999, patient safety and medical errors became paramount not only to health care providers but also to patients (health care consumers.).1 The report has been likened to removing the lid off Pandora's box as it relates to safety and error.2 Following this report and the heightened attention on medical errors, The Joint Commision release the standard RI.1.2.2:
The responsible licensed independent practitioner or his or her designee clearly explains the ourcome of any treatment or procedure to the patient and, when appropriate, the family, whenever those outcomes differ significantly from the anticipated outcomes.3
Despite the heightened attention to patient safety and quality of care, the Agency for Healthcare Reaseach and Quality (AHRQ)reports that patient safety continues to decline in the United States. The AHRQ estimated that in 2005 and 2006, 1 in 7 Medicare patients experienced an adverse event. The AHRQ estimated that overall measures of patient safety declined by nearly 1% in each of the previous 6 years.4
The good news is that a lot of work is taking place nationally to change this. The Institue for Healthcare Improvement (IHI) pblished a white paper in 2010 entitled "Respectful Management of Serious Clinical Adverse Events."5 This paper outlines the steps that our institutions can take to support the move forward to a new culture. Since to err s human, we have to accept that the practice of medicine will never reach perfection; therefore, our focus should change to one of reducing that error rate to the lowest possible level.
To do this, we have to increase awareness about the need for systems to support health care providers in delivering the best possible care to paitnets. We need to analyze our "bad outcomes" from this viewpoint. We also need to have increased transparency so the best minds can assist us in reaching the goal of the lowest possible errors. The IHI white paper is an excellent resource for the practical application of these principles.
With the changes noted above in the patient safety paradigm, health care providers are challenged with communicating unanaticipated outcomes and medical errors to patients and/or their families. While physician-paitient commnication has been recognized as an important aspect of paitnet care (aside from clinical outcomes and patient compliance), communication of "bad news," especially in the context or errors, can pose for some a insurmountable challenge.6
Here we explore these challenges as we attempt to lower the barries successful disclosure conversations as well as provide models of effective disclosure.
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The majority of patients (98%) wish to be informed of unintended outcomes or errors: The more severe the occurence, the higer the desire for information.7 Patients in particular want honest, prompt, and compassionate communication when mistakes occour.8
Disclosure of adverse events is associated with approval and relief by health care providers, higher ratings of quality by patients, an improved rate of recovery, a decrease in the number of malpractice suirts, and a decrease in the average settlements in the average settlement amount.9,10 However, health care providers and organizations continue to demonstrate reluctance to provide full disclosure for several reasons, including fear of litigation, thogh the exact impact and relationship of disclosures with litigation is difficult to ascertain.8,13
Full disclosure of medical errors is what patients want from their clinicians, and it is also ethically the right thing to do. Several institutions including the University of Michigan have recently implmented full disclosure programs for medical erros without any increase in liability costs or total claims.12
There is increased agreement that admission of a medical error is simply a factual statement.12 So why then, with the ethical obligation to disclose, paitents' desire to be told, and evidence to suggest that litigation and malpractice sosts are not increase, are clinicians reluctant and resistant to disclose medical errors? Furthermore, how do we move from "disclosure" to "communication"?
There are multiple barriers to disclosure of medical errors in addition to the fear of litigation. These barriers are psychological, legal, and based on personal experience. Table 1 lists these barriers collectively.13, 14
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OVERCOMING DISCLOSURE BARRIERS
The barriers are numerous, yet disclosre must occur. Several models are suggested here as a means to overcome the disclosure barriers. They are listed in Table 2.10,15,16
The FEARED factor acronym not only provides a sequence of statements but describes an emotion felt by most clinicians in these situations. All 3 models, perhaps one in particular, or an adaptation of each should assist clinicians in preparing for and conversing with patients about medical errors.
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CULTURE OF PATIENT SAFETY
Finally, it is equally important that health care organizations recognize the importance of disclosure in medical errors. A culture of patient safety with policies and procedures that enhance open communication between clinicians and patients is essential. All health care institutions should have written policies that address disclosure as it relates to timing, content of conversation, communication, and documentation of disclosure.
Clinicians need education and training in disclosure conversations just as they receive training and competency in procedures. If communication and disclosure were viewed as a procedure, clinicians could and would receive similar procedural training and feedback. Simulation of medical error disclosure conversations is essential for clinicians to overcome many barriers, as is now done in medical education and in the airline industry. Utilizing the clinical rotations in medical school as the initial encounter for clinicians to learn how to deal with it may not be the appropriate place any longer.
Some curriculums have implemented disclosure scenarios in the initial years of training that continued through the residency program. Utilizing simulations for these unusual scenarios, as we do with other examples such as shoulder dystocia or postpartum hemorrhage, should be routine. Presenting the continuum of the clinical event and adding the disclosure of a bad outcome at the end would bring the learner full circle and develop the skills necessary to improve our responses when the real event occurs.
Institutions can support disclosure training by making use of risk management and legal services. This helps to alleviate liability fears and thus complement the competencies we already include in our resident education, ie, professionalism, interpersonal and communication skills, and practice learning and improvement.
The authors report no actual or potential confl icts of interest in relation to this article.
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Patrice M. Weiss, MD, is Chair and Professor, Department of Obstetrics and Gynecology, Carilion Clinic/Virginia Tech Carilion School of Medicine, Roanoke, VA. Sandra Koch, MD, is District VIII ACOG Patient Safety Chair, Carson City, NV. Eduardo Lara-Torre, MD, is Residency Program Director and Associate Professor, Department of Obstetrics and Gynecology, Carilion Clinic/Virginia Tech Carilion School of Medicine. Pamela K. Scarrow, CPHQ, is Manager of Patient Safety and Quality Improvement, ACOG, Washington, DC.
- Institute of Medicine; Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
- Matlow A, Stevens P, Harrison C, Laxer RM. Disclosure of medical errors. Pediatr Clin North Am. 2006;53(6):1091-1104.
- The Joint Commission. Comprehensive accreditation manual. CAMH for hospitals: the offi cial handbook. Oakbrook Terrace (IL): JC; 2011.
- Kuehn B. AHRQ: US quality of care falls short: patient safety declining, disparities persist. JAMA. 2009;301(23):2427-2428.
- Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events. IHI Innovations Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2010. Available at www.IHI.org.
- Clinician-patient communication to enhance health outcomes. New Haven, CT: Bayer Institute for Health Care Communication workshop PowerPoint presentation. 2003.
- Witman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med. 1996;156(22):2565-2569.
- Ulene V. Malpractice system not a cure-all. Los Angeles Times, February 28, 2011. Available at: www.latimes.com/health/la-he-doctors-malpractice- 20110228,0,5507400.story.
- Ledema R, Mallock N, Sorensen R, et al. Final Report: Evaluation of the Pilot of the National Open Disclosure Standard. Sydney, Australia: University of Technology; 2007. Available at: www.safetyandquality.gov.au/internet /safety/publishing.nsf/Content/com-pubs_eval-pilot-nodstd.
- Weiss P, Miranda F. Transparency, apology and disclosure of adverse outcomes. Obstet Gynecol Clin North Am. 2008;35(1):53-62, viii.
- Marchev M. Medical malpractice and medical error disclosure: balancing facts and fears. Portland, ME: National Academy for State Health Policy; 2003. Available at: http://fl oridahealthinfo.hsc.usf.edu/RWJ2003 MedErrorDisclos.pdf. Accessed April 19, 2011.
- Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153(4):213-221.
- American Society for Healthcare Risk Management of the American Hospital Association. Disclosure of unanticipated events: the next step in better communication with patients. Monographs Task Force of the American Society for Healthcare Risk Management; 2003. Available at: www.ashrm.org/ashrm/education /development/monographs/monograph.disclosure1 .pdf. Accessed on April 19, 2011.
- ACOG Committee Opinion No. 380: Disclosure and discussion of adverse events. Obstet Gynecol. 2007; 110(4):957-958.
- Woods JR Jr, Rozovsky FA. What Do I Say?: Communicating Intended or Unanticipated Outcomes in Obstetrics. San Francisco, CA: Jossey-Bass; 2003.
- Communication of Unanticipated Outcomes and Medical Errors. New Haven, CT: Institute for Healthcare Communication, Inc. Workshop PowerPoint.