1. 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

2. 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

3. 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:

4. 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

5. 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

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. “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

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