John W. C. Entwistle III, MD PhD Associate Professor of Surgery Thomas Jefferson University April 25, 2015

Conflicts I have no conflicts relevant to this presentation

Case Presentation  55 y.o. male with severe aortic valve insufficiency and ascending aortic aneurysm  Underwent aortic root replacement with mechanical valve conduit  Failed to come off pump, with severe biventricular failure – presumed “poor protection”  Placed on biventricular support

Case Presentation  Transfer requested by referring cardiologist after 3 days of support  Arrived with profound liver and renal failure despite adequate VAD flows  Angiogram showed kinked left main  Heart failed to recover after LM stenting  Liver failure persisted  Support was withdrawn

Potential Errors  Failure to look for kinking of the left main coronary button  Placement of biventricular support in presence of mechanical aortic valve  Delay in requesting transfer to a hospital capable of managing this complex patient

Options  Stay silent  Wait for the patient/family to ask  Notify the other surgeon  Inform the patient  Of error; or  That care alternatives might have changed outcome  Inform the surgeon’s supervisor  Inform regulatory agency

Culture of Silence Lawton R and Parker D. Qual Saf Health Care 2002;11:15-18

Attitudes on Disclosure of Errors Made by Others  Survey of general practitioners in Iran  62.5 – 70% would inform the other physician and recommend they tell patient  92.7% expected to be informed by their peer of an error  20% believed it should be disclosed to patient  70% of these would disclose only if asked by patient Asghari F et al. Qual Safe Health Care 2009:18;

NEJM Poll  Vignette accompanying article on managing errors by other clinicians – misdiagnosis led to significant injury  Poll accompanied on-line version of article  1113 readers responded  Only 63% would inform the patient of the error committed by the other physician Gallagher TH et al. N Engl J Med ;18:

Would Disclosure Happen?  Survey with case vignettes given to attending and resident physicians, and medical students  Physicians are less likely to report error of others than their own error without patient asking (18% vs. 84%)  25% would suggest different care might have altered outcome  Main factor in not reporting was lack of information on details Sweet MP and Bernat JL. J Clin Ethics 1997;8(4): 341-8

How Would They Notify Patient?  15% would notify referring and let them tell patient  27% would let referring tell and then confirm  15% would tell patient directly  9% would schedule joint conference with referring and patient Sweet MP and Bernat JL. J Clin Ethics 1997;8(4): 341-8

Reporting in the Real World  Minor errors often are unreported  Serious errors are generally reported  General practitioners had a higher threshold than hospitalists and nurses  Some serious errors went unreported  Participants reported repercussions after reporting and difficult interpersonal relationships Firth-Cozens J et al. “Confronting Errors in Patient Care – Report on Focus Groups” 2002

Ethical Arguments to Report Error  Duty to be truthful to your patient  Silence suggests natural cause to illness  Informed consent requires patient knowledge of errors  Principle of reparations  Protection of others - Exposes repetitive injury - May lead to corrective action -Re-education/training -Alterations in policy/procedures Fost N. JAMA 2001;286(9):1079 Moskop JC et al. Ann Emerg Med 2006;48:523-31

Unique Barriers to Disclosure  Fear of being dragged into litigation  Fear of professional repercussions  Reputation  Referrals  Lack of information regarding incident

AMA Code of Ethics “Situations occasionally occur in which a patient experiences significant medical complications that may have resulted from the physician’s mistake or judgment. In these situations, the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred. Only through full disclosure is a patient able to make informed decisions regarding future medical care.” Opinion 8.12 “Patient Information” Updated June 1994

How to Disclose an Error to Physician  Arrange surgeon-to-surgeon discussion  Clarify surgeon’s thoughts and actions, and medical facts  Avoid pejorative terms like “error” and “malpractice”  Offer opportunity for other surgeon to disclose error These conversations may be “discoverable”* *Kreimer S. Neurology Today, Dec 5, 2013, 35-6

How to Disclose to Patient  Be honest and respectful  Report facts only  Do not exaggerate  Be careful making conclusions  Avoid inflammatory statements

What Not to Do  Mislead your patient about facts related to prior care  Make definitive statements of error based on incomplete information  Mistake differences in opinion or style as error or malpractice

Something to Consider Is the ethical duty to disclose the error of another the same as disclosing your own error when it is committed by your professional partner?