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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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