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Medical error disclosure: improving patient safety through better communication


Monica Enderlin’s father was a healthy and active 74 year-old cabinetmaker who enjoyed sailing and spending time with his four children and wife of 47 years. In March of 2009, he was admitted to hospital in Edmonton with a non-resolving pneumonia. Soon after admission, his condition took a serious turn for the worse.

“He was healthy and driving—he walked in and within a week was barely able to speak,” remembers Enderlin. “During the next two weeks my dad endured extreme pain and intolerable thirst, by the third week all of his organs had shut down.”

As the family watched in despair as the medical team struggled to determine the cause of his deterioration, a vague mention was made of a medical error. Not long after, and just three weeks after walking into hospital he passed away with his family by his side.

To err is human…

In 1999 the Institute of Medicine issued a landmark report entitled To Err is Human: Building a Safer Health System which estimated that up to 100,000 Americans die each year as a result of preventable medical errors.

Here at home, the 2004 Canadian Adverse Events Study reported that medical errors occur during 185,000 or 7.5% of hospitalizations across the country, and almost 37% of these errors are preventable.

A more recent estimate, published earlier this year in the Journal of Patient Safety is that as many as 440,000 Americans die each year from preventable medical errors. This would make medical error the third leading cause of death in the United States.

This groundbreaking research has raised global awareness about patient safety, leading to the launch of several initiatives aimed at reducing medical error including the Institute for Health Improvement’s 100,000 Lives Campaign and the Canadian Patient Safety Institute’s flagship Safer Healthcare Now! program.

…To disclose is not

Despite this focus on error prevention, much less attention has been paid to the process of medical error disclosure.

“Twelve years ago there was nothing in the literature,” reflects Dr. Wendy Levinson, the Sir John and Lady Eaton Professor and Chair of the Department of Medicine at the University of Toronto.

“The Institute of Medicine had done To Err is Human, but no one was talking about physicians disclosing errors; 10 years ago nobody talked about this topic,” Levinson notes. “There was a lot of the counter messaging and a culture of secrecy because people were worried about getting sued—I don’t think there was disclosure of errors to patients.”

In 2003, Levinson published a seminal study exploring patients’ and physicians’ attitudes about medical error disclosure. Levinson’s work revealed a disconnect between patients’ wishes and physicians’ actions.

Patients wanted disclosure of all harmful errors as well as an apology and detailed information about what happened, why the error occurred, how the error’s consequences will be mitigated, and how recurrences will be prevented. By contrast, physicians often avoided stating that an error occurred, why the error happened, or how recurrences would be prevented.

Levinsons’ 2003 study also reported that physicians’ reluctance to fully disclose medical error and apologize was often driven by a fear of litigation and concern about fracturing trust in the doctor-patient relationship. However, patients wanted an explanation, not to assign blame, but to understand what happened and to ensure that actions were being taking to prevent future events. In fact, earlier research reported that patients commonly filed malpractice suits as a result of insensitive handling and poor communication following medical error, because they wanted to ensure that similar errors were not repeated.

An international focus on openness

Ten years later after the publication of her study, Dr. Wendy Levinson says things have changed.

Levinson points to numerous guidelines on medical error disclosure that have burgeoned all across the world. These include the National Quality Forum’s Safe Practices for Better Healthcare and Harvard’s When Things Go Wrong in the United States, the National Patient Safety Agency’s Being Open policy in the United Kingdom, and the Canadian Patient Safety Institute’s Canadian Disclosure Guidelines.

The latter guideline was updated in 2011 and highlights that “disclosure must occur if there has been any harm related to a patient safety incident, or if there is a risk of potential future harm.” Central to the guideline are the principles of openness, honesty and patient-centeredness. In fact, the guideline encourages health care providers to explicitly apologize for their errors.

Hugh MacLeod, the Chief Executive Officer of the Canadian Patient Safety Institute, also acknowledges how critical medical error disclosure is to the prevention of future medical errors. “We have to be as proactive at error disclosure as we are in the front end at preventing errors,” he says. MacLeod points to the Canadian Patient Safety Institute’s Canadian Incident Analysis Framework, which provides methods and tools to assist in analyzing patient safety incidents.

A dearth of data

Despite these gains, patient safety experts still don’t know much about physicians’ disclosure practices.

“How much has it percolated into practicing physicians?” questions Dr. Wendy Levinson, “I don’t know.” “How often do practicing physicians make a mistake and disclose?” she asks, “I don’t know.”

The truth is no one really knows. Of the limited research on the topic, most is qualitative or survey-based. A 2006 survey of 2637 medical and surgical physicians in the United States and Canada reported that 98% of physicians endorsed disclosing serious errors to patients; however, 22% of respondents disagreed with the need to disclose minor errors that were not permanent or life threatening. When physicians were asked how they would disclose errors to patients, only 42% would explicitly state that an error occurred, and the majority would not provide specific information about preventing future errors.

Estimating the level of physician engagement in error disclosure is challenging considering that most health care systems, including Canada’s, lack a medical error reporting system. Where these systems exist, most rely on voluntary reporting of medical errors, which only captures a tiny fraction of medical error. Indeed a 2012 report released by the United States Department of Health and Human Services found that hospital staff reported 14% of medical errors to incident reporting systems. Most importantly, these data cannot capture whether individual physicians actually disclosed errors to patients, or simply documented events anonymously to local reporting systems.

Disclosure in an evolving health care system

Engaging health care practitioners in error disclosure is made more complicated by the current clinical environment where care is often delivered by multiple providers across multiple settings. Because of this, when a medical error occurs, responsibility may not actually reside with one individual.

This phenomenon, combined with the rapid turnover of providers, especially in the inpatient setting, means that physicians may be required to talk with patients about other clinicians’ errors. However, existing guidelines on medical error disclosure fail to address this complex and increasingly common situation.

These trends have health care leaders calling for more institutional support and responsibility for medical error disclosure. Recently, Dr. Levinson participated in a working group of experts in patient safety who published recommendations for communicating with patients about other clinicians’ errors. The recommendations highlight the need for a “collective approach to accountability,” and stress the importance of “institutional leadership.”

“I don’t think this is just about the individual,” say Levinson. “Errors are a systems problem and disclosure requires institutional support.”

Part of this support will need to focus on educating clinicians how to disclose medical errors in a patient-centric and respectful manner, especially when the error involves other clinicians. Levinson says educational efforts should be intensified for medical trainees, since research shows they may not be prepared to meet patients’ expectations for the open disclosure of harmful medical errors.

“I would call this a sophisticated communication skill,” notes Levinson. “One could think of this as a higher level communication skill like breaking bad news, and we need to teach physicians these skills.”

Levinson also notes that while the physician may ultimately disclose an error to a patient and their family, it really is a team effort, especially when multiple providers are involved in an error. “It’s a team effort, this is not a solo endeavour,” she comments. “It’s how the institution handles mistakes and how they learn from their mistakes.”

“A redefined medical culture”

Monica Enderlin and her family never really learned what caused her father’s death. Although mention of a medical error was made, the family had many unanswered questions, and closure has not been reached on her fathers’ death.

“We really lost faith in the system,” reflects Enderlin.” When medical errors happen, you need to find out what happened not to assign blame, but because it becomes an avenue for healing the continued trust in the medical system.”

Despite a heightened focus on patient safety and an explosion of guidelines on medical error disclosure, real change may require a cultural shift. Dr. Brian Goldman, an emergency room physician at Mount Sinai Hospital in Toronto and host of CBC’s White Coat, Black Art, has been a vocal advocate for such a change.

In a 2011 TED Talk that has received nearly one million views, Goldman implores physicians to talk about their mistakes. At the conclusion of his talk, Goldman describes “a redefined medical culture” that embraces medical error disclosure:

“The redefined physician is human, knows she’s human, accepts it, isn’t proud of making mistakes, but strives to learn one thing from what happened that she can teach to somebody else. She shares her experience with others. She’s supportive when other people talk about their mistakes. And she points out other people’s mistakes, not in a gotcha way, but in a loving, supportive way so that everybody can benefit. And she works in a culture of medicine that acknowledges that human beings run the system, and when human beings run the system, they will make mistakes from time to time. So the system is evolving to create backups that make it easier to detect those mistakes that humans inevitably make and also fosters in a loving, supportive way places where everybody who is observing in the health care system can actually point out things that could be potential mistakes and is rewarded for doing so, and especially people like me, when we do make mistakes, we’re rewarded for coming clean.”

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17 comments

  1. Eric

    This is completely shocking to me. I knew this was a problem, but to what extent I had no idea. I hope that healthcare policy begins to catch up with this and start protecting patients and their families from these kinds of unnecessary errors.

      • Tim Delaney

        I fear evidence-based medicine will have only a minor impact on errors in the complex systems of care we operate. There is a need to inculcate a culture of mindfulness and vigilance against error, and systematically to eliminate avoidable causes of large volume error such as handwritten orders, transcription of orders and prescriptions, and picking and preparation of medication doses.

        There is also an urgent need to avoid political spinning of safety data and to be careful about how numbers are presented. For example, in the otherwise excellent PRACtICe Study published in May 2012 by the GMC, it was stated in the Abstract that “the vast majority of the errors were of mild to moderate severity, with one in 550 items being associated with a severe error.” In 2011, there were 961.5 million prescriptions written in UK general practice. An error rate of 1 in 550 therefore means that there were that in that year, there would be 1.75 million prescriptions assciated with a severe error nationally. This a vast scale of severe error. The first step in creating a culture of safety is to confront the data in an honest manner, even when it is daunting.

  2. Boris Sobolev

    communication on patient safety should involve multiple channels: provider, hospital, health authority… in healthcare evaluation, we assess outcomes related to patient, to treatment, and to system… those give different perspectives on the performance of health systems… patient-related outcomes represent the effects of medical services on the patient’s physical function, mobility, emotional and intellectual performance, and self-perception of health… treatment-related outcomes represent biological and physiological changes in the patient’s condition as a result of receiving treatment within a particular health system… system-related outcomes represent the effects on the health system produced by the provicion of medical services to a patient population… recent book Health care federalism in Canada could be a good reading on contrasting the outcomes in measuring system performance

  3. Kathleen Finlay | Patient Protection Canada

    My experience with hospitals that intentionally concealed harm caused to my elderly mother, and the experiences of so many other patients and families, attest to a deep-seated pathology that too often surfaces in Canadian hospitals when it comes to disclosing errors, much less preventing them.

    The fact of the matter is that where there is no effective accountability to patients and families, which is largely the case in the hospital system, there is no incentive to disclose or to be truthful. Having spent the past several years reviewing thousands of pages on the subject, going back to Lucian Leape’s seminal “Error in Medicine” in 1994, I have come to the conclusion that the healthcare community is now where the chemical industry was in the 1960s. It took a massive change in the law to force necessary changes in behaviour on the part of the decision-makers involved. Where would we be today if we had relied upon the altruism or good will of that sector to make society safer?

    We need laws that would make it a criminal offense for hospitals to deliberately fail to disclose harm to a patient or to cover it up. And make no mistake, this happens every day.

    To those members of the healthcare professions who prefer a gentler approach as to how and when errors and harm should be disclosed, I say, with respect, that train long ago left the station.

    We are facing an epidemic of hospital harm in Canada, the United States and elsewhere. It is the third leading cause of death. Too many patients are being avoidably killed and injured and too many families are having their lives turned into a train wreck by unethical practices and deceit. Yet the knowledge about what to do to prevent this harm through better use of technology and best practices, for instance, is well documented.

    What does not exist is the necessary disincentive to withhold or cover-up vital information about the harm. For while some will continue to argue that errors will always occur by inadvertence, they cannot deny that the decision to withhold disclosing that harm or deciding to cover it up is always the result of a deliberate, intentional and highly premeditated act. It is the one that patients and families always view as the ultimate betrayal.

    That is one reason Patient Protection Canada (www.patientprotecton.ca) has spearheaded the patient and family campaign to end the epidemic of medical errors and hospital harm. But to end this epidemic, we need to eradicate the hospital culture of delay, denial and deception that too often follows these events.

    It might very well be human error to hit someone with your car on a dark and rainy night. But if you just drive off and fail to report it, human nature will be no defense in the face of the tough criminal proceedings that will follow.

    Too many patients and families have felt like the victims of a hit-and-run in their hospital experiences.

    • Elizabeth Rankin BScN

      Your commentary was excellent and to the point. I would suggest your group/organization lobby the Ministries of Health [across Canada] and other related parties, such as the CMA [Medical] and provincial physician organization, the CNA [Nursing] all provincial nursing organizations using this presentation and anything else your group has to provide to get things in place. In your own local town/city I would urge you to see if your hospital[s] will take on the challenge for others to bring about the needed change.

      I would add that there are some good Canadian examples of policies in place that can be used but obviously these are either ignored or don’t go far enough. One that I personally studied which is very good is “THE SCIENCE OF PATIENT SAFETY” developed by a team from Johns Hopkins from both the schools of Nursing and Medicine and the Armstrong Institute for Health & Safety. This course [online] was outstanding and it teaches how everyone in the system is required to make health and safety a priority from the CEO to the cleaning staff, and well beyond…anyone who works in the hospital and the patients and the visitors all play a role. The blame game is out..working together to make the system safe is! And this course get you there.

      Mistakes happen because we are human and we err but it is a flawed system that enables a continuing problem.

      Elizabeth Rankin BScN

      • Sean Power

        I’ve recently enrolled for the course you mention–it’s available on Coursera for any interested. https://www.coursera.org/course/healthcaresafety

        I’m surprised that the University of Michigan Health System study hasn’t been mentioned thus far in the discussion on error disclosure and patient safety. The Michigan Model centers on saying sorry when clinical care does not go as planned.

        http://www.uofmhealth.org/michigan-model-medical-malpractice-and-patient-safety-umhs

        The U-M Health System found that this “do the right thing” policy reduced the number of malpractice claims and, consequently, malpractice expenses. Especially in the context of the Canadian system, these dollars could presumably be re-invested into error prevention initiatives.

        Sean Power
        Community Manager
        Physician-Patient Alliance for Health and Safety
        http://ppahs.org/

    • Sophie Hankes LL.M Chair SIN-NL and IEU-Alliance

      Excellent commentary. As a victim of a medical error and continuous coverup by practically all doctors and as a legal consultant (LL.M) I founded SIN-NL in the Netherlands and the IEU-Alliance as European organisation to improve the position of victims of medical errors and to prevent medical errors.
      Please be aware that the current sytematic coverup of medical errors to victims of medical errors and their relatives is a deliberate decision of individual doctors, time and time again.
      Coverup also means: no followup diagnostics, no remedical medical care which causes additional unnecessary physical damage to the patient, which should have been avoided.
      Furthermore we found out that many lawyers collaborate behind the scenes with negligent doctors and pretend they defend victims of medical errrors. On top of that it has been proven that judges in high level courts in Europe even the European Court of Human Rights are corrupt, as they ignore facts and documents of medical negligence by individual failing doctors. Journalists dare not publish for fear of not receiving medical care……
      Apparently the old boys networks is very strong. It is up to the public with the help of dedicated journalists to expose the truth of these white collar crimes by doctors, lawyers and judges. Protect the patients worldwide!

  4. Fernando Barroso - Portugal

    It is essential to continue to promote this theme. Doctors, nurses and other health professionals – everyone makes mistakes. The health system has to help, learn from those mistakes and CHANGE

  5. Barb Farlow

    The public needs to be aware that systems are complex and errors are frequent because they can take actions to reduce their own risk of harm. When in hospital, they must SPEAK UP, politely and respectfully of course and be persistent if nobody seems to listen. It is essential to know and understand the plan of care. Patients/families should obtain their own records whenever possible, understand the purpose of each medication, follow up on tests and keep a binder/file and diary of everything if their condition is ongoing. A vulnerable patient who can’t speak for themselves should never be left alone in hospital. Finally, the public needs to be more aware of germs and infection in hospital and what they can do to reduce their risk.

  6. Paul Gallant

    This article is long overdue in such public space. Thanks for posting it. As a Leader on Call in the past, taking late night calls from other leaders around “what now, that a major error was just made?” What do we do? Sometimes these calls surprised me, depending on who was calling and of course the situation. I do not want to trivialize nor appear insensitive by being somewhat brief and to the point. Forgive me if this is how you interpret my comments.

    Call 1: “It looks like we inserted the tube into the lung by mistake. The patient is crashing and unlikely to make it. “Should we tell the family? When/What? “Yes, now and tell them THE TRUTH” was always my answer and that “we are very sorry this has happened” to begin with. That’s a good starting point, considering the horrible error we just made.

    Call 2: Sadly, a patient committed suicide while in a secure mental health unit. Do we tell the parent(s) what happened, when? YES, and NOW and we also help them with their trauma now plus we bring in a team to help both the care providers and other mental health patients who are also traumatized by learning of the death.

    Unfortunately, some of us in health care are
    “afraid of what errors lead to” beyond complications and death of a patient. Some fear for their jobs, their bosses job, reputation of the hospital/facility, and become “prepared” to wait and see whether this becomes a protected case. Can we delay telling the truth to the public? We, at times, forget why we first became clinicians, doctors or involved in health care: patient and family first.

    Let’s help create the best culture for patient safety and for true transparency when medical errors occur. We do this to help those and the families of those who we have harmed, to minimize future harm and accept that yes, we sometimes we make errors, sometimes we make lots of them. Protect our patients but let’s not protect our “stories,” let’s share them more.

  7. Cynthia Robinson

    I appreciate all of the comments and stories shared. I am a nurse that had a wrong side error and experienced the system cover-up and denial that continued throughout the litigation process. I was stunned to see how far the medical professionals will go to protect themselves while shifting the blame to the patient, as in my case, where the surgeon convinced a mediation judge (the hospital and surgeon legal teams knew from other cases) that I would have EVENTUALLY had a problem, so he did me a favor. Too bad I had no symptoms and nothing wrong with that side. Obviously, I have a gag order that prevents me from specifics, however, as a nurse I have tried to change the medical error reporting system and prevention for 5 years. I invented and patented a color coded system that works in preventing surgical errors. SEPS (Surgical Error Prevention System) has proven that errors and even near misses are stopping “Never Events”. But the battle continues as we try to get across to the surgeons and staff that SEPS protects them AND the patient, so why would you want to take a chance on making an error? Our pilots using SEPS software is making a difference and it is my ultimate goal to make SEPS a universal protocol.
    We also offer support to patients and the medical staff; the medical staff can remain anonymous in the tele-support group.
    If anyone is interested in furthering our mission for “ZERO EVENTS”, please contact me.
    Cynthia Robinson RN CEO
    http://www.sepsinfo.com
    Contact@sepsinfo.com
    602-300-3692

  8. Ross Hammond

    Fascinating article. Medical error disclosure. If you go to the Canadian Patient Safety Institute’s Canadian Disclosure Guidelines, (link above in the article), the use of the word error is only used 5 times in the whole 52 page document. And it’s use can only be found in the section “Avoiding the Use of “Error” in the Context of Disclosure.” In other words, physicians are not to use the term “error” when discussing errors with patients and families. My thoughts are this would just create a sort of dance most physicians/people would wish to avoid. Yet this article is about discussing errors.

    I was reading how in Manitoba, if a physician apologizes for any mistakes, that apology cannot be used against them in any trials. This would make for a good start in any of the provinces. When my parents were in the hospital, it would seem a management plan was adhered to only as long as that attending physician was on shift. Once his rotation was done, another would come in and everything would get adjusted again. This lack of consistency made it difficult for the family to follow how things were being done all the time. In the end, each time, there was much confusion and wondering why the management plan wouldn’t continue from one Dr to the next. Were there errors made? We haven’t the slightest idea.

  9. Bruce Smith

    https://community.sumofus.org/petitions/make-dr-s-in-canada-responsible-for-medical-errors?source=facebook-share-button&time=1439422862 this link will explain what we went through but it doesn’t tell you that your right, every time the shifts changed She would get different advice on weather or not She should move around even though She had a large blood clot in Her leg. She called the Nurses several times that night but each time a different one came in, 2 flipped the blanket back in the dark and said it was fine. 40 minutes later the morning Dr.s rounds started and by then Her leg was so swollen the skin was ripping. It turned into an very serious life threatening situation. How could 1 Patient have suffered through a calamity of medical mistakes?

  10. Bruce

    If a Doctor make a mistake
    THE College of Physicians and Surgeons of Ontario 80 College Street Toronto, Ontario Canada M5G 2E2 Telephone: 416-967-2617 1-800-268-7096 ext. 221
    They Reviews the case and 99.999% of the time find in the favor of the “DOCTOR”
    DOCTORS protecting DOCTORS
    How can look at another DOCTOR say his friend did something WRONG just will NOT happen.
    When a police officer make a mistake it is looked at by a public board, not by a FRIEND.
    “IT”S TIME FOR A CHANGE”
    PLEASE SHARE THANKS

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