1. What do patients and families need to know when errors occur? Susan Moffatt-Bruce MD, PhD, FACS, FRCS(C) Chief Quality and Patient Safety Officer Associate Professor of Surgery Associate Professor of Biomedical Informatics Associate Dean of Clinical Affairs, Quality and Patient Safety

2. Baby steps to full disclosure 2  “To Err is Human”-launch of the modern safety movement (2000)  Accountability of terrifying epidemic-Wachter (2004)  No blame paradigm?-Lucian Leape (2006)  No blame vs. Accountability-Pronovost (2009)  Medical error disclosure- Boothman (2010)

3. Principles that support disclosure: 3  The surgeons professional obligation  The surgeons integrity  The patient’s right to informed care  The patient’s right to informed consent

4. Professional Obligation AMA’s Code of Medical Ethics 4 "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." (1) 1. AMA Council on Ethical and Judicial Affairs. Code of Medical Ethics: 1997

5. Professional Integrity American College of Physicians “Ethics Manual” 5 “Physicians should disclose to patients information about procedural or judgment errors made during care, as long as such information is material to the patient's well-being. Errors do not necessarily imply negligent or unethical behavior, but failure to disclose them may. “(2) 2. American College of Physicians. American College of Physicians Ethics manual 1992.

6. Patients Right to Informed Care 6  Patients are entitled to honest information  Patients and families should not have the burden of trying to discover “what happened” when things go wrong  Financial burden to the patient should be relieved  Family must be kept informed along with the patient as to the long term care plan (good or bad!)

7. Patients Right to Informed Consent 7  Consent is an active process; not a drive by  Consent is based on understanding how the patient arrived at this point in their disease  Sound understanding of the potential success of the operation  Potential complications of the intended procedure and how they will be managed  Establishing accountability for both the surgeon and the patient-start the transparency conversation

8. 8 “Transparency, as defined as the free, uninhibited sharing of information has been touted as the single attribute of a culture of safety” (3) While physicians may be ethically obligated to disclose errors, pressures from society and the medical profession make it very difficult for physicians to rush to disclose. (4) Lack of transparency restricts critical information for individual patients, systems and impairs the quality of healthcare overall 3 Leape, Berwick,Clancy et al. Qual Safe Health Care 2009 4 Blendon R et al. NEJM 2002

9. Physician Attitudes to Reporting Errors 9 3038 US and Canadian physicians (4702 surveyed- 65% response rate)  Physician reported error involvement  53% serious  72% minor  62% near miss  51% physicians reported disclosing a serious mistake during the preceding year Gallagher et al. Transparency When Things Go Wrong: Physician Attitudes About Reporting Medical Errors to Patients, Peers and Institutions J Patient Saf 2014

10. 10 Predictors of attitudes supporting transparent communication:  Female  Younger  US (vs. Canadian)  Academic vs. Private  Previous disclosure education  Belief that disclosure decreased litigation  Belief that disclosure facilitated system change

11. Explore, do not ignore 11  Get the facts  Engage the family when they choose  Discuss prior to disclosure  Have a plan and continue to communicate it  Ask for help! Gallagher et al. NEJM 2013

12. Talking to the patient and family 12  Ensure disclosure for every sentinel event  Engage physician and a peer support  Accompany physician and offer ongoing support  Inform supervisors as well as leaders  Open the conversation and leave it open  Engage legal but not openly involve them  Peer review of event  Determine if early settlement is appropriate  Be realistic; be fair

13. Critical Event (Adverse or Sentinel Event) On Call Critical Event / Result Officer (pager 9876) CQO Quality Review/ SEDG Risk Management Medical Director Division DirectorChair STAAR triage CMO / DMA /CEN CEO Board Communications Critical Event Response Engage Attending Physician

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17. Potential benefits 17  Communicating openly and honestly: full disclosure shown to improve outcomes  Improved surgeon-patient relationships  Improved patient and family satisfaction  Improved surgeon well being  Decreased litigation  Decreased malpractice costs  Support “Just Culture” and accountability

18. Commitment to change 18  Early and informed conversations with patients  Institutional transparency and support  Coaching and early disclosure algorithms So what do patient’s need when something goes wrong? Clarity (what happened) Consistency (build trust and engage) Caring (be empathetic and fair )