Eliminating the Barriers to Error Disclosure

Wendy Levinson, MD
University of Toronto Faculty of Medicine

Studies in many countries have documented the frequency of medical errors that result in harm to patients. The patient safety movement calls for recognizing and reporting errors and correcting any underlying systemic defects to prevent similar errors in the future. Both within the medical profession and among the general public, there is a strong call to disclose errors to patients and their families. Disclosing errors to patients and families has not been standard practice in the health care field, and it presents challenges for physicians and institutions. Nevertheless, evidence of the benefits of disclosure continues to increase.

Studies confirm that patients want to be informed about errors in their care. Patients want specific information, including an explanation of what went wrong, the implications of the error for their health and subsequent care, and an indication of how the health care team will learn from the error, to keep it from happening to other patients. Furthermore, patients want health professionals to apologize for the error. Although providing this information to patients and their families may sound simple (albeit not easy), physicians have faced multiple barriers to conducting these conversations.

One of the main barriers has been a fear of malpractice litigation. In the past, malpractice insurance companies and hospitals have told physicians to be cautious about admitting errors and have advised them to limit the information they provide about errors to avoid implying fault. Here is where the landscape has changed in several ways. First, several institutions have implemented policies to support full disclosure to patients and families and have monitored the impact, if any, on malpractice claims and payments. The Veterans Administration Hospital in Lexington, Kentucky, and, more recently, the University of Michigan reported that actively providing information did not have an adverse impact on malpractice claims. On the contrary, in Michigan, malpractice claims and costs fell in the 3 years after implementation of a full-disclosure policy. The COPIC Insurance Company, a company in Colorado offering malpractice liability insurance, has had a similar experience after implementing a program of training and coaching of physicians in error disclosure. Although the evidence is not based on rigorously designed research, it supports a rapidly evolving impression that the fear that error disclosure will increase malpractice risk is unfounded.

Another development that supports disclosure is the emergence of apology laws in many states. In general, these laws allow physicians to apologize to patients without the statement, “I’m sorry,â€? being used in a legal case to indicate liability. The degree of protection provided by these laws varies between states, but the overall effect has been to further reduce one of the major barriers to the disclosure of errors.

In addition to developments that have decreased the barriers to disclosure, some developments that encourage disclosure have occurred. The Joint Commission for the Accreditation of Healthcare Organizations requires that hospitals tell patients about unanticipated outcomes that have resulted in a serious consequence for the patient. Although this requirement has been in force for some years, its implementation has been facilitated by a recent Safe Practice guideline on disclosure developed by the National Safety Forum. This guideline provides hospitals with more specific guidance about what to disclose and how to do so and makes recommendations for hospital administrators about how to build a culture in the hospital that supports these efforts. This new Safe Practice guideline is likely to help hospitals develop training in disclosure for health care workers and create systems for disclosing errors. Individual physicians should familiarize themselves with services of this nature that may be available to them.

Furthermore, a variety of organizations have developed workshops to train professionals on the specific communication skills of disclosure. For example, the Bayer Institute for Healthcare Communication offers a workshop that has been widely disseminated. Some postgraduate training programs are incorporating this topic into their curricula. Several of these programs allow physicians to practice disclosing errors to a patient surrogate. Overall, it is clear that this is a challenging area, and few physicians have had any training in these communications skills.

I anticipate that in the next few years, the disclosure of medical errors will become a more common topic for education, and physicians will take advantage of these educational opportunities and will apply what they have learned. Greater willingness to admit mistakes will not only meet our patients’ expectations for open and transparent communication about medical errors but will create opportunities for physicians to improve the quality of care we provide.

1. Gallagher T, Waterman AD, Ebers AG, et al: Patients’ and physicians’ attitudes regarding disclosure of medical errors. JAMA 289:1001, 2003 [PMID 12597752]

2. Kraman SS, Hamm G: Risk management: extreme honesty may be the best policy. Ann Intern Med 131:963, 1999 [PMID 10610649]

3. To Err Is Human: Building a Safer Health System. Institute of Medicine: National Academy Press, Washington DC, 1999 http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf

4. Leape LL, Berwick DM: Five years after To Err Is Human: what have we learned? JAMA 293:2384, 2005 [PMID 15900009]

5. Institute of Medicine report on medical errors: could it do harm? N Engl J Med 342:1123, 2000 [PMID 10760315]
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