When Things Go Wrong: Disclosure of Medical Error Sigall K. Bell, MD Beth Israel Deaconess Medical Center Institute for Professionalism and Ethical Practice, Children’s Hospital Boston Harvard Medical School

How are we doing? 2/3 errors are not disclosed Blendon et al NEJM 2002 Even when disclosure happens, it often does not meet patient expectations Gallagher et al, JAMA 2003 Trainees often do not learn to disclose Wu et al, JAMA 1991; White et al, Acad Med 2008; Bell et al, Acad Med 2010 Well, how are we doing, When it comes to communicating after harm? Simple answer: we fall short. 2/3 errors are not disclosed, even when they are, the disclosure often does not meet pt expectations. And when we turn our attention to our next generation of doctors, those who will be responsible for disclosure conversations with tomorrow’s patients, they are not gaining adequate experience to do so

When Things Go Wrong: Voices of Patients and Families, CRICO/RMF 2006 Well what do patients want, when things go wrong? I’m about to show you a short excerpt from a documentary film WTGW – several patients and family members from diverse demographic, socioeconomic, and geographic backgrounds. But despite these differences, some common themes emerge … see if you can identify some of them. When Things Go Wrong: Voices of Patients and Families, CRICO/RMF 2006 Available at: http://www.rmf.harvard.edu/

Patient Attitudes about Errors Disclosing medical errors to patients: Recent developments and future directions Patient Attitudes about Errors Conceive of errors broadly Desire full disclosure of harmful errors Worry that health care workers might hide errors Information patients want disclosed Explicit statement that error occurred What happened, implications for their health Why it happened How will recurrences be prevented Importance of an apology Some powerful and important messages…well here’s what the literature says about pt attitudes regarding error: …again, apology… “you have no idea how far…” Gallagher JAMA 2003

Clinicians’ Attitudes about Errors Disclosing medical errors to patients: Recent developments and future directions Clinicians’ Attitudes about Errors Define errors more narrowly than patients Agree in principle with full disclosure Want to be truthful, but experience barriers to disclosure Fear of litigation Lack of confidence in communication skills Lack of institutional support What about physicians? Gallagher JAMA 2003

Why do patients sue? “Studies show that the most important factor in people’s decisions to file lawsuits is not negligence, but ineffective communication between patients and providers.” “Malpractice suits often result when an unexpected adverse outcome is met with a lack of empathy from physicians and a perceived or actual withholding of essential information.” Clinton & Obama, NEJM 2006 Vincent C, Lancet 1993

Reports from the field: University of Michigan Disclosure policy adopted 2001; 3 components: Acknowledge cases in which a patient was hurt because of medical error and compensate these patients quickly and fairly Aggressively defend cases that the hospital considers to be without merit Study all adverse events to determine how procedures could be improved Here’s one report from the field – this is the Univ of Michigan Clinton and Obama, NEJM 2006 Kachalia et al, Ann Intern Med 2010

University of Michigan Here are their data over the first 4 years of the program Clinton and Obama, NEJM 2006 8

University of Michigan: 9 years later Reduced total liability costs by about 40% Reduced the number of new lawsuits by about 65% Decreased the time to claim resolution by about 25% Kachalia et al, Ann Intern Med 2010

Mock Trial Data Same case presented to two juries: one with disclosure, one without Disclosure resulted in much smaller judgments ($millions) No disclosure – jury assumed the hospital and clinicians were hiding information With disclosure – jury focused on meeting the needs of the patient rather than on punishing the organization Gallagher, JAMA 2009 Popp, PL. J Healthc Manag 2003 Robbennolt JK. Mich Law Rev 2003 10

The Nurses’ Perspective Nurses pay heavy emotional toll - nightmares, fear, guilt, and stress from even minor errors Nurses fear being “thrown under the bus” by physicians in disclosure conversations Nurses “walk on eggshells” during pre-disclosure period Physicians can avoid the patient & family, nurses cannot Disclosing errors to physicians sometimes as stressful as disclosing to patients Shannon et al. Jt Comm J Qual Patient Saf 2009;35:5 11

Clinician support programs: The “Second Victim” Have errors in your practice negatively impacted your life? Attendings Your job satisfaction 42% Your confidence in your ability as a physician 47% Your professional reputation 13% Your anxiety about future errors 61% Your ability to sleep 40% From Gallagher’s slides ostracized, shamed, considered incompetent Gallagher Arch Int Med 2006 12

“Facing our Mistakes” “Everyone, of course, makes mistakes, and no one enjoys the consequences. But the potential consequences of our medical mistakes are so overwhelming that it is almost impossible for practicing physicians to deal with their errors in a psychologically healthy fashion. Most people—doctors and patients alike—harbor deep within themselves the expectation that the physician will be perfect. No one seems prepared to accept the simple fact of life that physicians, like anyone else, will make mistakes.” Painfully, almost unbelievably, we physicians are even less prepared to deal with our mistakes than the average lay person is. The medical profession simply seems to have no place for its mistakes. There is no permission given to talk about errors, no way of venting emotional responses. Indeed, one would almost think that mistakes are in the same category as sins: it is permissible to talk about them only when they happen to other people. Hilfiker, NEJM 1984

How Are Patients Currently Experiencing Disclosure? Colorado pilot data (n=140 events) % respondents Pilot data, COPIC; Gallagher JAMA 2009