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Full and timely disclosure of errors
to patients: honesty is the best policy
From the February 23, 2000 issue
Do healthcare providers have a moral and ethical obligation
to disclose medical errors honestly and promptly to involved
patients/families? The mother of a child who is blind, mute,
and suffering from cerebral palsy provided testimony on this
issue at a hearing held last week by Senator James Jeffords.
The child's condition was caused by a brain hemorrhage secondary
to puncturing the lung during a fluid aspiration attempt,
but the error was not disclosed to the child's parents. Three
years later, an obstetrician discovered the error while investigating
information provided by the mother in preparation for the
birth of her second child. The mother testified, "I was able
to accept the fact that a human being made a serious mistake,
but I felt betrayed, hurt and angry toward the hospital who
had lied to us and continued to lie to us for three years."
1 Although this error took
place years ago, a more recent study of medical residents
found that less than 25% informed the patient/patient's family
of errors.2 Research conducted
by ISMP and LaSalle University last year also showed that
only 44% of medication errors that respondents considered
serious were disclosed to the patient/patient's family.3 Given
the current legal climate, organizations and practitioners
may continue to be reticent about disclosing mistakes to patients,
fearing that it could provide an otherwise uninformed patient
with a basis for a lawsuit. However, research shows that a
large percentage of lawsuits are motivated not by negligence,
but by poor communication, a breakdown in trust between providers
and patients, suspicion of a cover-up, or desire for revenge.4-5
The Veterans Affairs (VA) Medical Center in Lexington, Kentucky,
recently reported encouraging data on a courageous and ethical
institutional policy to disclose errors to patients and to
equitably compensate patients/families for their actual loss.6
Since adoption, the policy has led to many settlements, including
five that probably would not have resulted in claims if the
hospital had not honestly disclosed the errors. Unexpectedly,
however, this policy has not caused a flood of lawsuits, and
payments for claims have been moderate. When compared to other
VA medical centers, the Lexington facility is in the top quartile
for number of claims filed, but at the bottom quartile for
payments.
While most organizations encourage and embrace honest and
full disclosure of errors, many may be struggling to standardize
that process. Consider establishing guidelines, approved by
the hospital's ethics committee, for a process similar to
the Lexington VA Medical Center's policy, as follows. Unless
disclosure is needed to obtain consent for immediate treatment,
assign a multidisciplinary risk management committee to promptly
investigate the facts. If the event was caused by error and
the error resulted in the loss of the patient's function or
life, have the chief of staff ask the patient/family to meet,
face-to-face, with him or her, the facility attorney (and/or
risk management representative), and a quality manager. Provide
all details as sensitively as possible. Place emphasis on
the regret of the institution and the personnel involved and
any actions that have been taken to prevent similar events.
Answer questions and, if appropriate, make an offer of restitution
based on a reasonable calculation of loss. Recognize that
disclosure will likely upset the patient/family and guard
against acting defensively or ignoring the patient/family
by role playing before hand with those meeting the patient/family
and all practitioners involved in the event.
Full disclosure of errors and just compensation for injuries
seems to be a solution that is both ethical and cost effective.6-7
It restores organizations and practitioners to a patient advocacy
role, putting the patient's interests first, while potentially
minimizing the organization's financial impact. It encourages
open communication about errors and can help to restore the
public's trust in health care. Most importantly, it's the
right thing to do.
References: 1. Ring W. Lawmaker
ponders medical errors. Philadelphia Inquirer, Feb. 17, 2000.
2. Wu AW et al. Do house officers learn from their
mistakes? JAMA. 1991; 265:2089-94. 3. Wolf ZW et al.
Responses and Concerns of Health Care Providers to Medication
Errors. 2000. In review. 4. Green JA. Minimizing malpractice
risks by role clarification. The confusing transition from
tort to contract. Ann Intern Med. 1998; 109:234-41. 5.
Hickson GB et al. Factors that prompted families to file medical
malpractice claims following prenatal injuries. JAMA. 1992;
267:1359-63. 6. Wu AW. et al. Handling hospital errors:
Is disclosure the best defense? Ann Intern Med 1999; 131:970-72.
7. Kraman SS, Hamm G. Risk management: Extreme honesty
may be the best policy. Ann Intern Med. 1999; 131: 963-67.
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