Disclosing medical errors: Why we need to get it right.

I write a lot about patient safety.  I’ve explored how new digital health technologies can dramatically cut medical error, how simulation training improves patient-centered outcomes, and how we can transform the way we think about morbidity and mortality so that next time, we can do better.   As a physician, I’m entrenched in a culture that compulsively strives for the best, whether that means the top score on an anatomy exam or the pristine execution of evidence-based medicine.  It often seems, despite all logic, that imperfection is surmountable.

But doctors are humans.  And we slip up sometimes.  Often these slip-ups are minor and inconsequential to the wellbeing of the patient.  Sometimes they have a real clinical impact: a patient is taken back to the operating room, her hospitalization is prolonged because of a delay in treatment orders, she receives the wrong medication but the adverse effects are transient.  Rarely – and memorably – our slip-ups are lethal.

Culturally, we’re beginning to accept this.  Guidelines put forth by the National Quality Forum recommend the full disclosure of adverse or unanticipated events, and evidence has shown that practicing transparency benefits both patients and their families.   But a recent article in JAMA Surgery points to the therapeutic effect of full disclosure on physicians, as well.

Pointing to the fact that the emotional fallout of an adverse event often renders physicians the “second victims” of medical error, the authors sought to understand how surgeons experience the disclosure process.  After surveying 62 surgeons, they found that most of the participants perform only 5 out of 8 disclosure items recommended by the National Quality Forum.  Those who left items out were significantly more likely to be negatively impacted by the event.  Furthermore, physicians who reported greater difficulty in discussing the adverse event were four times as likely to report that the event negatively affected their lives.   In short, when disclosure of error is smooth and formulaic, everyone seems to do better.

Realizing the profound emotional effect of adverse effects on physicians, the authors advocate for the implementation of full disclosure programs nationwide.  In the meantime, the following are key components of a successful disclosure, according to the National Quality Forum.

  • Provide the facts about an event. What is known about why it happened? Has there been any event analysis?  Share what is known, and focus on what it means for the patient.
  • Discuss whether the event was preventable. The issue of preventability was often unaddressed by surgeons in the survey, but it’s important to patients.
  • Express regret the unanticipated outcome. Be explicit.
  • Provide a formal apology. “I am sorry that this has happened” is simple, but usually well received.
  • Express concern for the patient’s welfare, and provide emotional support.
  • Make it timely – within 24 hours.
  • Commit to investigating the root of the error. And always feedback the results.
  • Always discuss disclosure with patient safety and risk management stakeholders.
  • Seek the support of a disclosure and improvement support system, if available.

By Nicole Van Groningen