TABLE OF CONTENTS

Acknowledgements
Contact Information

Prelude
Rationale for Another Teaching Skills Manual
Structure of the Toolbox
A Brief Review of Relevant Educational Theory
Teaching Ethics in a Clinical Setting: Finding
  Teachable Moments

Preview of Toolbox Features Yet to Come

Core Teaching Skills
Overview of Skill-Based Teaching
Goal Setting
Giving Feedback
Using the Group
Addressing Emotion
Common Teaching Challenges
  (& Tips for Recovering from Them)


Unique Teaching Issues with Special Topics
DNR Orders
 Medical Errors

Resources for Teaching
Annotated Bibliography
Domains for Small Group Teaching

        


     

RATIONALE:

Since the 1999 Institute of Medicine report "To Err is Human," a resurgence of interest has occurred in reducing medical errors and improving the quality of healthcare. Yet despite our best efforts, harmful medical errors will continue to occur. The issue of whether and how to disclose harmful medical errors to patients requires that physicians integrate their understanding of bioethics, doctor-patient communication, quality of care, and team-based care delivery. Despite a long-standing general consensus among ethicists that harmful errors should be disclosed to patients, evidence exists that at present such disclosure is uncommon. The issue of whether and how to disclose medical errors represents an ideal opportunity for educators to explore the interface between ethics and communication with their learners.

PITFALLS:

  • Many physicians worry that disclosing errors to patients will precipitate lawsuits. Despite strong evidence that patients are more likely to sue physicians when communication breaks down, fear of malpractice suits will be a significant barrier for open discussion about errors with patients.
  • Physicians can get mixed messages from risk managers and hospital administrators who explicitly say physicians should not apologize to patients as an apology is an admission of fault. How to handle apologies effectively is a key issue for error disclosure.

SUGGESTED PROCEDURE:

Patient Safety Basics. The emerging patient safety movement provides an important backdrop for discussions regarding error disclosure. Previously, it was assumed that most medical errors were due to providers who were either incompetent or lazy. Using this "bad apple" framework, one would improve the quality of healthcare by seeking out the bad apples and removing them from the barrel, a process often referred to as "quality by inspection." A primary goal of the new patient safety movement is to educate providers about the substantial flaws in this bad apple framework.

Drawing from lessons learned in other high risk industries such as nuclear power and aviation, patient safety experts assert that most medical errors are due not to incompetent providers but rather due to flaws in the systems of care. These flaws, often referred to as "latent errors," represent the breakdowns in the healthcare system that made the error itself more likely to happen. These patient safety principles have important implications for preventing medical errors. If one understands the system contribution to most medical errors, there should be a diminished tendency to blame the involved healthcare providers.

Furthermore, the patient safety movement argues that not only is the bad apple approach to medical errors inaccurate, this framework promotes secrecy about errors. When one seeks to improve quality by identifying and removing bad apple providers, it is natural that healthcare workers who make errors would want to keep these errors to themselves. Such secrecy surrounding errors prevents proper analysis of errors and inhibits efforts to prevent recurrences of the error. More open communication among healthcare workers about errors, as well as decreasing the "culture of blame" in healthcare around errors, are both seen as prerequisites to understanding why errors really happen and how they can be prevented.

Another important component of the patient safety movement has been to promote greater clarity about patient safety terms. It is critical that one be able to differentiate an adverse event from a medical error (see Figure 1).

  • Adverse Event: harm resulting from the process of medical care rather than from the patients' underlying disease.
  • Medical Error: failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.

From Figure 1 it should be noted that the vast majority of medical errors are not associated with an adverse event (i.e. do not cause harm). Similarly, most adverse events are not associated with a medical error and therefore are not preventable. For the remainder of this module we will focus primarily on the overlap between medical errors and adverse events, namely medical errors that cause harm.

Ethical Rationale for Error Disclosure. A variety of ethical rationale have been offered for disclosing harmful medical errors to patients.

  • Informed Consent: In some respects, error disclosure is a form of informed consent, conveying important information to patients that they need to make informed decisions about their subsequent medical care. To that extent, it is important to recognize that informed consent is a positive obligation, i.e., an obligation physicians have to come forward with relevant information that patient should know, rather than waiting for the patient to extract the information from the physician with probing questions.
  • Truth-Telling: Other ethicists justify the need to disclose errors as a form of truth telling, which suggests such errors should be disclosed even if the information is not essential to informed decision-making.
  • Justice and Fairness: Theories of justice also support error disclosure, as such information is often a prerequisite to a patient accessing appropriate compensation for their injuries.

Current Practices. Despite these compelling ethical rationale, there at present exists a disclosure gap; our current clinical practices do not come close to meeting the practices recommended. A variety of studies have documented error disclosure rates of approximately 30 percent. Multiple barriers inhibit disclosure, ranging from fear of malpractice to shame and embarrassment from admitting to a patient that one has made an error. Furthermore, few physicians have had formal training in error disclosure, and therefore may feel quite uncomfortable conducting such conversations.

More recent work suggests that this disclosure gap primarily relates to differences between doctors and patients about the content of disclosure. Physicians generally agree with the basic principal that harmful errors should be disclosed to patients, but in practice choose their words carefully when talking with patients about errors. This careful word choice typically involves acknowledging that an adverse event took place but not explicitly admitting that the adverse event was due to an error. Such partial disclosure conversations can actually be counterproductive, as patients' belief that important information about an error is being hidden from them is a common precipitant of malpractice suites.

This disclosure gap also reveals unexplored ethical complexities in error disclosure. For example, no consensus currently exists regarding basic standards for the content of disclosure. In addition, oftentimes it is unclear whether an error happened and whether the error was associated with an adverse event. Furthermore, little consensus exists regarding the disclosure of errors that caused minor or no harm, whether fatal errors should be disclosed (since the patient can no longer derive any benefit from any disclosure), or whether to disclose harmful errors that have happened to patients who are likely to die soon regardless of whether the error took place. Such complexities represent ideal opportunities for teachers to probe how learners are balancing the ethical complexities involved in error disclosure.

KEY ELEMENTS IN THE DISCLOSURE PROCESS.

1. Understanding Patient Preferences for Error Disclosure. Recent studies have found that patients desire a consistent set of information about harmful errors (outlined in Box 1).

Patients generally report wanting this information provided to them without having to ask their physicians a litany of questions about the error. Patients desire such information even about relatively minor errors. However, important gaps exist in our knowledge of patients' preferences about error disclosure. Most of these prior studies have solicited patients' preferences when they are not acutely ill. Patients who have just experienced a medical error may have different preferences than patients considering a hypothetical situation when they are feeling well. In addition, it is not known in any prospective sense whether providing patients with this information improves outcomes such as patient trust, satisfaction, and the intent to file a lawsuit.

2. Understanding the disclosure process and possible pitfalls. Physicians should approach disclosure conversations with considerable caution, foresight, and planning. Thorough analysis of an event is usually necessary before it can be definitively determined that a harmful error took place. In addition, many physicians experience great emotional distress following an error, distress that can distort the physician's judgment about whether an error took place and if so whether the error caused harm. While patients should be provided timely information about harmful errors in their care, physicians should resist the urge to tell patients about errors until the facts of the case are clearly known. In many institutions, formal disclosure policies exist to ensure proper analysis and planning takes place before the disclosure occurs. Trainees should consult their attending physician or other senior supervisor before discussing an error with a patient.

3. Disclosure Communication Skills. Many of the basic communication skills that apply to delivering bad news are equally applicable to disclosure conversations. Physicians should choose an appropriate physical setting for such conversations. Careful consideration should be given to which team members should be present. For example, having a nurse manager and/or pharmacist present, if the error in question involved these services, can provide patients with useful information about why an error occurred. However, having too large a team present for a disclosure conversation can intimidate the patient and should be avoided.

Error disclosure involves both communicating information as well as addressing the patient's emotions. Over emphasis of either dimension, such as responding primarily to the patient's disappointment and anger but sharing little information about the event in question, can lead to poor disclosure conversations. In addition, clinicians should recognize that error disclosure is more than just giving bad news to patients. Error disclosure involves possible culpability on the part of the clinician and therefore may feel risky to physicians in ways that simply sharing bad news does not. This fact makes it especially important that physicians consciously reflect on their own emotions during the disclosure conversation and consider how these emotions are effecting their communication with their patients. Comments perceived by the patient as rationalizations or defensive on the part of the physician, though a natural reaction in response to angry comments made by the patient, can fuel patient anger and are to be avoided.

PLANNING THE CONTENT OF THE DISCLOSURE CONVERSATION.

Planning a disclosure conversation requires careful consideration on the part of the physician about what specific words to choose when describing the event to the patient. As above, patients want physicians to explicitly state than an error occurred, describe what the error was and why the error happened, how error recurrences will be prevented, and to apologize. In particular, physicians may underestimate patients' desire to know why an error happened and how recurrences will be prevented, information which shows patients that the physician and institution have learned from the event and have plans for preventing recurrences. Physicians must balance their interest in meeting patients' preferences with other concerns and recommendations, such as the advice many physicians receive from risk managers that the errors not be disclosed in a way that admits liability or that places blame.

Many physicians worry that in disclosing an error they could actually precipitate a lawsuit. The relationship between disclosure and malpractice is complex. It is fair to say that overall disclosure does not appear to stimulate lawsuits, and may in fact make lawsuits less likely. In individual cases, however, it is possible that even optimal disclosure could precipitate (or fail to prevent) a lawsuit. This uncertainty regarding the relationship between disclosure and malpractice makes consultation with colleagues and with risk managers of paramount importance before disclosing an error.

The deliberations physicians go through while deciding what words to use in disclosing an error to patients provide important teachable moments about balancing conflicting values and priorities and then operationalizing these decisions through effective communication skills. The following cases can be used to elicit discussion and foster skill practice.

Vignette A

You have admitted a diabetic patient to the hospital for a COPD exacerbation. You handwrite an order for the patient to receive "10 U" of insulin. The "U" in your order looks like a zero. The following morning the patient is given 100 units of insulin, ten times the patient's normal dose, and is later found unresponsive with a blood sugar level of 35. The patient is resuscitated and transferred to the intensive care unit. You expect the patient to make a full recovery.

Questions for Discussion

  • What were the errors in this case? Why did they happen?
  • Imagine you are this patient's attending physician and are meeting with them after the error to describe what happened. All learners will want to tell patients "the truth" about what happened. What is the truth? How should it be communicated to the patient?
  • Truth telling exists along a spectrum ranging from frank lies to statements that are literally true but deceptive or misleading. What are the pros and cons of using the following language to disclose this error? "You received more insulin than you needed." "You had a bad reaction to the insulin." "There was a miscommunication about your insulin order."
  • Should the physician explicitly say the words "error" or "mistake"?
  • Should the physician accept responsibility for this error? If so, what specific language would communicate such acceptance of responsibility?
  • Should the physician apologize and if so what words should they say?
  • Consider variations on this vignette, such as increasing harm (patient suffers permanent neurologic damage such as a stroke with hemeperisis), patient dies from hypoglycemia (or little or no harm) patient becomes slightly dizzy but the insulin overdose is quickly recognized and corrected with no ICU admission necessary)

Vignette B-Hyperkalemia

You start an outpatient with hypertension on a new medicine with a common side effect of increasing the potassium level. The patient's baseline potassium level is normal (4.0). You order a repeat potassium blood test to be drawn the next week, but forget to check the lab results. Two weeks after the patient begins this new medicine they start feeling palpitations and go to the emergency room. In the ER the patient experiences an episode of ventricular tachycardia requiring cardioversion. The patient's potassium level at the time of this event is 7.5. The patient is hospitalized for four days, and makes a full recovery. The patient returns to your office for a follow-up visit. On reviewing the patient's chart you see the overlooked labs, which showed the patient's potassium had risen substantially from 4.0 to 5.6. Had you seen this elevated potassium earlier, you would have stopped the new medicine and treated the hyperkalemia, likely avoiding the life-threatening arrhythmia.

Questions for Discussion

  • What were the errors in this case? Why did they happen?
  • Imagine you are this patient's attending physician and are meeting with them after the error to describe what happened. All learners will want to tell patients "the truth" about what happened. What is the truth? How should it be communicated to the patient?
  • Truth telling exists along a spectrum ranging from frank lies to statements that are literally true but deceptive or misleading. What are the pros and cons of using the following language to disclose this error?
  • Should the physician explicitly say the words "error" or "mistake"?
  • Should the physician accept responsibility for this error? If so, what specific language would communicate such acceptance of responsibility?
  • Should the physician apologize and if so what words should they say?

PEARLS

  • Patients want physicians to explicitly state than an error occurred, describe what the error was and why the error happened, how error recurrences will be prevented, and to apologize.
  • In most cases, disclosure does not appear to stimulate lawsuits, and may in fact make lawsuits less likely.

REFERENCES

  • Gallagher TH. Medical errors in the outpatient setting: ethics in practice. J Clin Ethics 2002;13(4):291-300.
  • Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA 2003;289(8):1001-7.
  • Hebert PC, Levin AV, Robertson G. Bioethics for clinicians: 23. Disclosure of medical error. CMAJ 2001;164(4):509-13.
  • Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press; 2001.
  • Kachalia A, Shojania KG, Hofer TP, Piotrowski M, Saint S. Does full disclosure of medical errors affect malpractice liability? The jury is still out. Jt Comm J Qual Saf 2003;29(10):503-11.
  • Kohn LT, Corrigan J, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press; 2000.
  • Leape LL. Reporting of adverse events. N Engl J Med 2002;347(20):1633-8.
  • Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med 1997;12(12):770-5.