Medical Error Disclosure: Easier Said than Done

by Martha Kerr

The atmosphere of the current health care system continues to inhibit physicians' ability to disclose details of medical errors, while at the same time, patients are demanding full disclosure, according to a recent study of physicians and patients published in the Journal of the American Medical Association (2003;289:1001-1007). The issue is particularly relevant for the elderly, who may have impairments in communication and family members scattered around the country who may need to be included in discussions. Patients, their families, and physicians are left frustrated, the authors conclude (also see AHRQ Launches Patient-Safety Initiatives, in this issue).

For their study, Thomas H. Gallagher, MD, Assistant Professor in the Departments of Medicine and Medical History and Ethics at the University of Washington in Seattle and colleagues organized a series of 13 focus groups. Six groups were made up of patients only, four of physicians only, and three groups consisted of both patients and physicians.

Overall, 52 patients, who were all active users of health care services, and 46 physicians were involved. The mean age of the patient population was 60.

All participants were asked about their attitudes towards medical-error disclosure. In addition, patients were asked whether physicians provided the information they wanted about medical errors; both patients and physicians were asked about their emotional response to an error and whether their emotional needs were met.

Patients and physicians were presented with a hypothetical scenario and several variations on the theme. In one such scenario, a patient receives a dose of insulin that is 10 times what was prescribed; in another, the patient has a "near miss," in which a nurse catches the error before the dose is administered. Other variations on the insulin-dosage error were also put forth, and the participants were asked to react.

In the next phase of study, patients were asked, for each scenario, whether they would want information about the error. Physicians were asked if they would disclose details of the error to the patient.

Responses were similar for both patients and physicians, but each group worded its response differently. Patients indicated that they wanted full disclosure, including the circumstances surrounding the error and why the error occurred, how the sequelae of the error could be ameliorated, and how the error could possibly be prevented in the future. Patients also expressed the need for emotional support from their physician following the error, and an apology, which they stated that they rarely received.

Just like their patients, physicians supported the concept of full disclosure, but they said that they need to "choose their words carefully." Physicians tend to explain the circumstances surrounding an error without actually calling it a medical error, observed Dr. Gallagher, and they said that an apology is an invitation for a lawsuit.

Barriers to Disclosure

"Physicians want to be truthful about medical errors, but experience a number of barriers to providing patients with the information they want," Dr. Gallagher said. Barriers include:

• Fear that disclosure will precipitate a malpractice suit.
• Concern that error disclosure can actually harm patients by causing anxiety and diminished confidence in their doctor.
• Belief that disclosure conversations would be awkward and uncomfortable, especially for doctors who see errors as a personal failing.
• Lack of training in conducting error-disclosure conversations.

"We believe that patients' satisfaction with error disclosure will improve as physicians meet the needs that patients have articulated," Dr. Gallagher noted. "Physicians need to recognize the basic set of information that patients desire following medical errors and enhance their skills at providing this information."

Blame-Free Environment Needed

A fundamental problem is that both patients and physicians consider medical errors to be the result of incompetent medical care, indicating that physicians blame themselves for the incident. Dr. Gallagher asserted that "most errors are not the result of incompetent providers, but rather defective systems of health care delivery.

"The first step will be to educate patients and physicians about why medical errors happen, to decrease the natural tendency of both parties to find someone to blame following an error. Changing how patients and providers conceptualize medical errors is a realistic goal, but one that will take time to accomplish."

A frequently recurring response from physician participants in the study's focus groups was fear of litigation with medical-error disclosure. "While doctors agreed in principle that harmful errors should be disclosed to patients, their disclosure statements frequently did not provide the information patients desired about errors," Dr. Gallagher commented, adding that "there is evidence from a variety of sources that full error disclosure may actually make patients less likely to sue. Yet, many of the physicians in our study were not persuaded that this is the case. Continued education of physicians about the reasons patients file malpractice claims may decrease physicians' concerns about disclosure."

Both patients and physicians said that their emotional needs following medical errors were unmet. A solution, Dr. Gallagher suggested, is improved communication between patients and physicians, which could help prevent future errors. "Hopefully, this paradigm will help physicians see error disclosure as a way to help both the affected patient as well as future patients." In addition, "institutions should continue to work towards establishing a blame-free culture around medical errors and avoid punitive responses to errors." This can be accomplished in part by ensuring that institutional policies encourage physicians to provide patients with information about errors, training physicians in error disclosure, and supporting the emotional needs of health care workers involved in errors.

Litigation: The Tie that Binds

Commenting on the study, American Medical Directors Association President James E. Lett, II, MD, CMD, observed that "the issue is not whether mistakes occur, but how the medical community responds. Fears about litigation, unquestionably and appropriately, color the current behavior around medical mishaps," said Dr. Lett, who is also Medical Director for several nursing facilities in Sacramento, CA. He echoed Dr. Gallagher's assertion that more communication is the best prevention for malpractice suits." The evidence appears to reveal that lawsuits may be more about communication and being heard than issues of 'malpractice.'"

Anger is the common denominator in malpractice courts, and the health care provider involved is frequently accused of "stonewalling," by refusing to provide information, Dr. Lett continued. Yet, "an expression of personal upset [by the health care provider] over the unintended result, accompanied by an explanation of how the system will be altered to prevent further similar episodes, can go a long way towards resolution of anger."

Initiation of the discussion by the provider can also be helpful in facilitating the communication process. A good relationship between patient and physician, where health care decisions have been made jointly and responsibility has been shared, is an invaluable asset when medical-error disclosure is needed. However, Dr. Lett acknowledged, this is easier said than done.

"For those of us in geriatrics and long-term care, the issue of disclosure becomes more difficult logistically," Dr. Lett said. "The patient or spouse will likely have physical ailments that make travel for face-to-face contact difficult. Infirmities such as hearing impairment and dementia can render discussions on arcane medical points exceptionally complicated.

"Additionally, children and other family members with decision-making legal authority who need to be included often live not just miles, but time zones away from the site of care. Multiple calls at odd times, sometimes to several different people, can change a discussion the geriatrician may feel is clear to a discussion that is impossibly confused," said Dr. Lett, adding that these efforts are not reimbursed.

Moreover, such discussions can "open old family wounds and fractures. Here, the geriatric physician enters unknown family dynamics where a seemingly innocent statement can trigger responses that may appear inappropriate to us, but painfully obvious if the background is known.

"Full disclosure, which I believe health care professionals prefer, will only occur when society is willing to acknowledge their culpability and be willing to alter it," Dr. Lett asserts. "A tort system gone mad has spooked all to the point that any expression of regret or sorrow somehow appears to be an admission of guilt. However, it is only through acceptance of errors that we can continue to improve."

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