Hospital Medicine

Medical Errors

I. Problem/Challenge.

Challenges after medical error

Medical errors are relatively common in the care of hospitalized patients and may result in serious morbidity and mortality. Although patient safety efforts continue to improve the quality of inpatient care, some errors remain inevitable. How hospitalists respond to errors may deeply affect the involved patients, healthcare workers, and hospital. A timely, empathetic, and transparent approach is needed.

After an unanticipated outcome, several challenges often emerge. Initially, it may be difficult to discern what caused the adverse outcome and whether it is due to an error. Second, clinicians may be uncertain about whether and how to discuss the error with the patient. Third, clinicians will likely suffer strong negative emotions and stress themselves. Finally, hospitalists should share the mistake with their institution for system improvement and risk management purposes. Recognizing and effectively responding to medical errors are critical skills for hospitalists.

Why do errors occur?

Most errors involve a combination of individual and systems failures rather than a single etiology. Reason's widely accepted Swiss-Cheese model suggests that harmful errors result from the failure of multiple systems, all of which align to allow an error to penetrate the standard stopgaps. Communication failures are the most common contributors, but often require interaction with care provider cognitive lapses and latent system flaws to injure patients. Root cause analysis is a common method of studying all potential contributions to an error.

Why should hospitalists disclose harmful errors to patients?

There is widespread consensus that patients harmed by errors should receive prompt, open disclosure and a full apology. This chapter refers to harmful medical errors, as disclosure of errors which do not cause harm is controversial. The rationale for full disclosure is multifaceted.

First, disclosure meets patient expectations to be informed about harmful errors made in their care. Disclosure also builds the foundation for identifying and meeting the patient’s emotional and practical needs after an error. Conversely, failure to discuss errors in a timely, open, and empathetic manner could damage the patient's trust in the hospitalist. Second, there is a strong ethical rationale for disclosing errors to patients. Disclosure supports the principles of beneficence, justice (allowing patients access to compensation), autonomy (patients may make different decisions about subsequent care), informed consent (patients would not agree to care if they did not expect to learn about its outcome), and fidelity (commitment to truth-telling). Third, open disclosure also meets regulatory, and in some states, legal expectations. Finally, evidence suggests that full disclosure may improve, rather than worsen, malpractice risk and expenditures.

How well do physicians currently perform disclosure?

Unfortunately, current error disclosure practices fall short of patient expectations. Evidence suggests that less than half of harmful errors are disclosed to patients. Even when disclosure occurs, physicians often struggle to provide the information and emotional support desired by patients. There may be several reasons for this gap. Although clinicians are committed to transparency about mistakes, few physicians have received training on error disclosure. Second, clinicians’ normal reflexes following errors are to keep what happened to themselves, rationalize the error, and to avoid the emotions they and their patients experience. These tendencies may be amplified when physicians have previously received advice to avoid disclosure for fear of triggering lawsuits or when they fear a punitive response from their hospital or insurer.

How often are errors reported?

Errors are under-reported at many hospitals, resulting in missed opportunities to improve faulty systems. Hospitalists should play a central role in reporting errors involving inpatients. Contacting institutional risk management is often an important step in both reporting and marshalling resources for understanding the error.

How do errors affect clinicians emotionally?

Hospitalists should also anticipate a strong personal emotional response. Many physicians experience loss of confidence, anxiety, sleeplessness, guilt, or anger after a mistake. This emotional response may limit their job satisfaction, lead to burnout, and challenge readiness to care for future patients.

II. Identify the Goal Behavior.

Communication about medical errors

Comprehensive communication after a medical error involves:

  • Reporting the error to hospital quality improvement and patient safety representatives

  • Disclosure to the patient (and/or family if appropriate)

  • Discussing the error with peers and hospital patient safety leaders in a protected forum for quality improvement and education

What should be disclosed?

Harmful medical errors should be disclosed in each circumstance. Proper disclosure should include:

  • Explicitly stating that an error occurred if that is conclusively known (this means using the word "error" or "mistake" without equivocation)

  • Revealing the nature of the error and the clinical implications of the error

  • The reason for the error

  • How similar errors will be prevented

  • An apology for the error

What else do patients expect?

In addition to the providing truthful and accurate information and an apology, patients expect the physician to approach them with sincerity and empathy. Patients will likely experience complex emotions including sadness, grief, anger, disbelief, a sense of broken trust, and fear. It is important to understand and address the patient's emotional response as much as possible.

Who should be involved?

Disclosure should be directed by the attending physician for the patient. Each training institution may have specific policies regarding the role of trainees, but students and residents should first seek the assistance of their attending, rather than disclosing alone. Other healthcare workers are commonly involved in errors in the hospital, and it is often important for the attending physician to include nurses, pharmacists, and others in the disclosure conversation.

III. Describe a Step-by-Step approach/method to this problem.

  • Attend to the acute care needs of the patient. Once the patient has been stabilized, the error disclosure process can be contemplated.

  • Notify your hospital or malpractice insurance risk manager. Many risk management teams have "just in time" coaching to guide clinicians through the disclosure process. Additionally, risk managers will also likely conduct an impartial analysis of what caused the error, helping to gather accurate information for you to share with the patient.

  • Plan for disclosure, involving team members and a disclosure coach if possible. Critical issues to consider include:

    • Who should be present? If other team members were materially involved in the error, engage them in preparing for disclosure. Determining roles and viewpoints in advance is essential.

    • Review the chart and discuss the care with involved healthcare workers to confirm facts and avoid speculation.

    • Prepare an agenda for who will share what information.

    • Anticipate patient questions and emotional reactions. Prepare for questions about any additional care or preparation for long-term consequences that may be required.

    • In most instances, it will be helpful to practice disclosing the mistake to a coach or risk manager to refine the exact phrases to be used and anticipate responses. Examples of challenging questions include requests for a new care team or requests for financial compensation.

  • Meet with the patient and family for an initial disclosure conversation as soon as possible after discovery of the event, ideally within a few hours and no later than 24 hours. Be attentive to the setting and process. Arrange a quiet room with adequate seating that focuses on the patient. Allow adequate notice such that family can attend. Open the meeting by introducing all participants.

  • This initial disclosure may be limited by the available facts, but should seek to disclose what is known without speculation. Explain that an error occurred, what the error was, and how it occurred. Explain the mistake in straightforward terms and allow time for silence or questions.

  • Be attentive to non-verbal cues: Make eye contact, adopt an open body posture and face the patient sitting at their level or below. Keep your tone of voice warm, concerned, and respectful.

  • Apologize with a clear and honest communication of regret. "I'm sorry for what happened to you" is acceptable after any adverse event when error is not suspected. "I'm sorry that we harmed you with our mistake" or "I'm sorry for this mistake" is appropriate if an error has occurred.

  • Outline steps to provide ongoing care and steps to investigate what is not yet known about the error.

  • Explain who will speak with the patient or their representative next. Anticipate that disclosure will require more than one meeting. Follow-up is essential for rebuilding trust and sharing the results of an event review. Hospitalists should avoid statements about compensation. If this question arises, acknowledge that it is legitimate and arrange for risk managers or financial executives to consider the request before the follow-up meeting.

  • Offer support services to the family. In addition to your own expressions of empathy, you may have access to a chaplain or other religious leader, a social worker, or psychologist to address ongoing emotional needs. Understand that the patient and family may partially blame themselves for not preventing the error. It is generally appropriate to express that they should not feel responsible for the outcome.

  • Although local documentation policies may vary, it is generally expected to promptly document that you discussed the error with the patient and took appropriate steps to meet ongoing care needs.

At follow-up meetings:

  • Answer questions that have arisen and present results of an event review. The hospitalist often plays a supporting role in this stage, with representatives from risk management discussing the institutional response to the medical error.

  • This may be an appropriate time for risk managers to address financial restitution, such as writing off charges or providing a financial compensation offer.

  • Share steps taken to prevent error recurrence. Surveys indicate some patients file lawsuits because they sense that step was necessary to prevent other patients from being harmed.

  • Sharing the design of new system improvements can defuse this motivation and assure the patient that their injury was taken seriously.

  • Seek support yourself. Clinician stress is significant in these error settings, even when disclosed. Do not hesitate to tend to one's own needs once the patient has been settled in. If support services are not available through your hospital or malpractice insurer, U.S. clinicians can consider contacting Medically Induced Trauma Support Services (http://mitss.org/clinicians_faq.html) for guidance.

IV. Common Pitfalls.

Common pitfalls in error disclosure

Failure to plan

Although some clinicians worry that planning may make error disclosure appear formulaic or rote, not planning for the conversation can lead to much more uncomfortable conversations. For example, failing to arrive at consensus before group disclosure or not spending time to anticipate patient questions may result in surprises that are difficult to negotiate spontaneously. Although it is possible to be too careful in choosing your words, a mixture of planning and being yourself is prudent.

Failure to disclose

Clinicians cite multiple barriers to disclosure, such as concern about triggering a lawsuit or fear of losing the patient's trust. Although these are reasonable concerns, evidence suggests that empathic error disclosure and apology may help maintain trust and deter litigation. Among patients seeking malpractice claims, a commonly cited motivation was the sense that information was withheld from them. Complete and voluntary disclosure may help counter this perception. Some physicians may invoke therapeutic privilege with the concern that disclosure will do more psychological harm than good. However, patient surveys routinely demonstrate that patients want to hear about all unanticipated outcomes, regardless of how emotionally upsetting the information may be.

Limiting disclosure content

Research indicates that physicians tend to limit details about the error and expect the patient to ask clarifying questions. However, the patient may lack the expertise necessary to know what questions to ask and the doctor risks appearing dishonest. Unprompted and complete disclosure of facts can avoid this pitfall.

Limiting or qualifying an apology

Many clinicians express concern that apologizing will amount to an expression of culpability and refrain from expressing sincere regret, thereby missing an opportunity to support the patient. Apology laws exist in most states to protect expressions of regret, but apology is strongly recommended regardless of these laws. Seeking advice from a coach about the exact wording of an apology can be especially helpful to avoid miscommunication about the cause of the outcome. The benefit of an apology may be damaged by qualifications. Avoid apologies that include the word "but" (e.g., "I'm sorry, but if the lab had only called me..." or "There was a mistake, but it wasn't that bad"). Avoid rationalization (e.g., "These things happen to the best of people" or "The mistake didn't change the outcome").

Failing to attend to the patient's emotional needs

Physicians may overly focus on sharing information to the detriment of addressing patient emotions. Inquiring about patient responses or helping patients to name their feelings may be useful. Avoid defensiveness or arguing with patients in response to anger. Maintaining an open demeanor and acknowledging the legitimacy of the patient's reaction may help.

Not seeking emotional support

Surveys indicate that physicians typically suffer from anxiety, loss of sleep, loss of job satisfaction, and other negative emotions after an error. Many healthcare organizations and malpractice insurers have systems to provide emotional support for clinicians involved in medical errors, but they are underutilized. Strategies associated with emotional recovery and personal growth include: discussing the error, disclosure and apology, dealing with imperfection, preventing recurrences, and teaching others.

Falling on your sword

Clinicians should also take care to not immediately blame themselves for an error in judgment. Following an adverse event, clinicians naturally speculate about the cause based on limited information and wonder whether an error occurred. A helpful approach is the "substitution of foresight" approach, in which the clinician runs the case by a similarly trained colleague without disclosing the negative outcome, in order to gauge whether a similarly trained colleague would have differed in their management. It is not appropriate to immediately disclose to a patient or family that you as a clinician made an error without first examining with one's peers whether your judgment was reasonable given the information known at the time. However, discussing the adverse outcome and indicating plans to investigate its cause would be appropriate.

Concerns about the medical malpractice insurance cooperation clause

Many hospitalists are employed by self-insured institutions that do not utilize a cooperation clause. However, some third party insurance carriers have a cooperation clause which states "the insured shall not, except at his own cost, make any payment, admit any liability, settle any claims, assume any obligations or incur any expense without the written consent of the company." This clause is not applicable when the physician has notified the insurer and works with them to plan disclosure, highlighting the importance of reporting possible errors, and seeking disclosure coaching.

Blaming or shaming healthcare team members at the "sharp end" of the error

In the vast majority of cases, healthcare workers involved in an error were performing work diligently and with good intentions. A common set of latent process errors tends to underlie many harmful errors, regardless of who is involved. As a result, any healthcare workers may become the second victim of the latent error. Provided there is not reckless behavior, physicians should promote a just culture and avoid punishing or humiliating staff members involved in the error. Reckless behavior does warrant punishment from the institution, but not the physician. A culture of blame exerts a chilling effect on patient safety by deterring reporting to the institution for quality improvement as well as disclosure to the patient. At its worst, it may prompt patients to seek unwarranted litigation.

Not reporting the error to the institution’s incident learning system

Incident learning systems exist to help prevent error recurrence, and their use promotes a systems approach to error. The process of a root cause analysis and objective evaluation of an incident can uncover a myriad of other contributing factors of which the clinician was unaware.

V. National Standards, Core Indicators and Quality Measures.

Specific standards for error disclosure have only recently emerged and do not address all of the complex nuances of disclosure. Although statements from professional societies such as the American College of Physicians, the American Board of Internal Medicine, and American Medical Association identified disclosure as an ethical obligation, they did not provide practical advice on whether or how clinicians should carry out these conversations. The Leapfrog Group publicly reports information on aspects of hospital processes, but no national bodies currently measure the quality of error disclosure or publicly report outcome measures.

National standards

Joint Commission

Hospitals must adhere to the following standard in order to maintain hospital accreditation: "Patients must be informed about all outcomes of care, including unanticipated outcomes". Although this standard does not specify the content of disclosure, it drove the rapid adoption of disclosure policies in United States hospitals. Consult your hospital's staff manual for local policy regarding implementation of this requirement.

National Quality Forum

The NQF issued a Safe Practice recommendation that "following serious unanticipated outcomes, including those that are clearly caused by systems failures, the patient and, as appropriate, family should receive timely and transparent clear communication concerning what is known about the event." This Safe Practice recommends that institutions support disclosure by creating formal policies for disclosure, reporting, and mitigating risks. They also urge institutions to provide disclosure training, just-in-time coaching, and emotional support for both providers and patients. Regarding the actual disclosure, they endorse the following content and principles:

  • Include the facts about the error

  • Communicate empathically, including an expression of regret

  • Commit to investigating the event

  • Disclose the error in a timely fashion, preferably within 24 hours of discovery of the event

  • An apology should be offered when it is clear the outcome was caused by errors or systems failure

Institute for Healthcare Improvement

The IHI monograph "Respectful Management of Serious Clinical Adverse Events" outlines steps hospital leaders should take to foster effective disclosure. They highlight ways to build an institutional culture of safety, recommend creating a crisis management plan, and provide checklists for the institutional response listed by three priorities: The patient and family, the front-line clinical staff, and the organization. Available at http://www.ihi.org/resources/pages/ihiwhitepapers/respectfulmanagementseriousclinicalaeswhitepaper.aspx.

Harvard Hospital Consensus Statement

This influential guide titled "When Things Go Wrong, Responding to Adverse Events" outlines expectations of hospitals and providers after an error. Available at: http://www.macoalition.org/documents/respondingToAdverseEvents.pdf.

Quality measures

Leapfrog Group

The Leapfrog Group publicly rates how hospitals comply with their standards for managing serious errors. Compliance is determined by the presence of hospital policies aligned with these standards: Following a Serious Reportable Event (Never Event), hospitals should:

  • Apologize to the patient and/or family

  • Report the event within 10 days to at least agency (Joint Commission, state reporting agency, or a patient safety organization)

  • Perform a root cause analysis

  • Waive costs related to the event and

  • Make this policy available

Ethics manuals

Links to relevant ethical manuals are provided below. Although they indicate consensus around support of the principle of error disclosure, none provide practical advice or detail best practices.

American Medical Association, Section 8.121: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion8121.shtml

American College of Physicians: https://www.acponline.org/running_practice/ethics/manual/manual6th.htm#disclosure.

ABIM Medical Professionalism Project: PUBMED:11827500.

VI. What's the evidence?

Mazor, KM,, Greene, SM,, Roblin, D,, Lemay, CA. "More than words: patients' views on apology and disclosure when things go wrong in cancer care.". Patient Educ Couns. vol. 90. 2013. pp. 341-6.

(This nicely lays out the exact elements of apology, behavior, and emotional handling that patients expect.)

White, AA,, Brock, DM,, McCotter, PI,, Hofeldt, R. "Risk managers' descriptions of programs to support second victims after adverse events.". J Healthc Risk Manag. vol. 34. 2015. pp. 30-40.

(This establishes the availability of emotional support programs at US hospitals intended for clinicians involved in medical errors.)

Plews-Ogan, M,, May, N,, Owens, J,, Ardelt, M. "Wisdom in Medicine: What Helps Physicians After a Medical Error?". Acad Med.. vol. 91. 2016.

(This work expands the understanding of how clinicians can successfully recover and develop wisdom after an error.)

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