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July
2007: VOLUME
4, NUMBER 11
Disclosure
of Medical Errors
[EDITOR'S
NOTE: For Respiratory Therapists interested in receiving CE credit for
this program, please note that the map that illustrates the individual
state requirements for CE credits has been updated. To view the map,
please visit
this page.]
In
This Issue...
Since
the publication of the 1999 report from the Institute of Medicine on
errors in medical care, researchers and quality of care experts have
worked diligently toward designing, implementing, and evaluating error
reduction strategies. More recently, these efforts have included studies
of both physician and patient attitudes toward the disclosure of medical
errors.
In this issue, we review recent
literature on parents’ perceptions of medical errors in the care of
their children, pediatricians’ attitudes surrounding communication of
errors, and the characteristics of complete error disclosure. |
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Course
Directors
Edward
E. Lawson, MD
Professor
Department of Pediatrics
Division of Neonatology
The Johns Hopkins
University
School of Medicine
Christoph
U. Lehmann, MD
Assistant Professor
Department of Pediatrics
Division of Neonatology
The Johns Hopkins
University
School of Medicine
Lawrence
M. Nogee, MD
Associate Professor
Department of Pediatrics
Division of Neonatology
The Johns Hopkins
University
School of Medicine
Mary
Terhaar, DNSc, RN
Assistant Professor
Undergraduate Instruction
JHU School of Nursing
Robert
J. Kopotic, MSN, RRT, FAARC
Director of Clinical
Programs
ConMed Corporation |
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GUEST
AUTHORS OF THE MONTH |
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Commentary:
Pamela
Kimzey Donohue, ScD, PA-C
Director
of Performance Improvement and Safety
Division
of Neonatology
The Johns
Hopkins University
School
of Medicine |
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Reviews:
George
Kim, MD
Research
Associate
Neonatology
and Health Sciences Informatics
The Johns
Hopkins University
School
of Medicine |
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Guest
Faculty Disclosure
No faculty member
has indicated that they have received financial support for consultation,
research or evaluation or has a financial interest relevant to this
literature review.
Unlabeled / Unapproved Uses
The authors have indicated that there will be no reference
to unlabeled/unapproved uses of drugs or products in this presentation.
Course
Directors' Disclosures |
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At
the conclusion of this activity, participants should be able to:
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Identify
the key elements of complete error disclosure |
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Discuss
the currently identified barriers to error disclosure |
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Explain
the relationship between error disclosure and litigation |
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COMPLETE
THE POST TEST
Step
1.
Click on the appropriate link
below. This will take you to the post-test.
Step
2.
If you have participated in a
Johns Hopkins on-line course, login. Otherwise, please register.
Step
3.
Complete the post-test and course
evaluation.
Step
4.
Print out your certificate.
Respiratory Therapists
Visit
this page to confirm that your state will accept the CE Credits
gained through this program or click on the link below to go directly
to the post-test.
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As
neither pediatric health care systems nor pediatric providers are infallible,
errors happen in the medical care of children. Sharek and colleagues1 report
74 adverse events for every 100 patients admitted to a neonatal intensive
care unit (NICU); studying 749 patients and 17,106 hospital days in
15 NICUs, they found the number of adverse events ranged from 0 to
11 per infant. It is not surprising, therefore, that 93% of the pediatricians
surveyed by Garbutt et al2 reported involvement in a medical
error.
Although the majority of pediatricians
profess to support disclosing errors, less than half actually do so.2,3 A
complex combination of personal and professional attitudes forms the
basis for failure to disclose errors,3 with barriers including
the fear of litigation, the inability to admit a mistake, and the fear
of implicating other providers.4 Physician shame is also
a powerful deterrent to error disclosure, and nowhere may this be truer
than in pediatrics. According to Kaldjian et al,3 92% of
physicians agree with the statement: "When I make a medical mistake,
I am my own worst critic." Pediatricians not only have trouble forgiving
themselves but also fear that others, including their patients’ parents,
will be unforgiving.
However, little is known about
parents’ perceptions of medical errors. In the only paper published
to date targeting a pediatric population, Hobgood et al5 showed
that parents want full disclosure of all medical errors, regardless
of severity. The study also suggests that there may be racial differences
in how parents perceive medical errors. Data from this study should
encourage providers to disclose all errors to parents, even those they
perceive to be minor, and thus avoid making assumptions about what parents
want to know or should know about their child’s medical care.2
The need for transparency surrounding
a medical error in pediatrics is highlighted by the case study presented
by Keatings et al,6 in which communication concerning the
circumstances leading to the death of an 11-year-old girl was both delayed
and misleading. Poor communication between parents and physicians contributes
to malpractice litigation.7Parents have been shown to be
more satisfied with the quality of care and less likely to initiate
legal action after an error if communication is honest and forthcoming.7,8 Parents
also value physicians who listen and allow sufficient time for questions.
Professional organizations such
as the Joint Commission and National Quality Forum stress the importance
of properly communicating a medical error and endorse a 4-step process:
1) describe what happened as soon as it is known; 2) take responsibility;
3) apologize; and 4) review what steps are being taken to avoid a similar
error in the future.4,9 Although these recommendations provide
a straightforward framework, physicians have difficulty adhering to
them in the high-stress context of error disclosure. Further, few physicians
receive training in how to disclosure errors, and most have poor skills
in doing so. Providers often disclose an error without "connecting the
dots," ie, making it clear that a medical error caused the harm experienced
by the patient.10 When asked, most physicians want coaching
in how to do a better job. Using a simulation center could provide physicians
and other healthcare professionals with experience in communicating
errors before they are faced with the reality.
And directly to the point of
this issue, research is urgently needed to help guide error disclosure
in the NICU environment where exposure to high-risk medical care is
prolonged.
References
| 1. |
Sharek
PJ, Horbar JD, Mason W, et al. Adverse
events in the Neonatal Intensive Care Unit: Development, testing,
and findings of an NICU-focused trigger tool to identify harm in
North American NICUs. Pediatrics 2006;118;1332-1340. |
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| 2. |
Garbutt
J, Brownstein DR, Klein EJ, et al. Reporting
and disclosing medical errors: pediatricians' attitudes and behaviors. Arch
Pediatr Adolesc Med. 2007;161:179-185. |
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| 3. |
Kaldjian
LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE. Disclosing
medical errors to patients: attitudes and practices of physicians
and trainees. J Gen Intern Med. 2007;22:988-996. |
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| 4. |
Matlow
A, Stevens P, Harrison C, Laxer RM. Disclosure
of medical errors. Pediatr Clin North Am. 2006;53:1091-1104 |
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| 5. |
Hobgood
C, Tamayo-Sarver JH, Elms A, Weiner B. Parental
preferences for error disclosure, reporting, and legal action after
medical error in the care of their children. Pediatrics.
2005;116:1276-1286. |
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| 6. |
Keatings
M, Martin M, McCallum A, Lewis J. Medical
errors: understanding the parent's perspective. Pediatr
Clin North Am. 2006;53:1079-1089. |
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| 7. |
Hickson
GB, Clayton EW, Githens PB, Sloan FA. Factors
that prompted families to file medical malpractice claims following
perinatal injuries. JAMA. 1992;267:1359-1363. |
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| 8. |
Donn
SM. Medical
liability, risk management, and quality of health care. Semin
Fetal Neonatal Med. 2005;10:3-9. |
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| 9. |
Gallagher
TH, Studdert D, Levinson W. Disclosing
harmful medical errors to patients. N Engl J Med. 2007;356:2713-2719. |
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| 10. |
Fein
SP, Hilborne LH, Spiritus EM, et al. The
many faces of error disclosure: a common set of elements and a definition. J
Gen Intern Med. 2007;22:755-761. |
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REPORTING
MEDICAL ERRORS: AN OVERVIEW |
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Matlow
A, Stevens P, Harrison C, Laxer RM. Disclosure of medical
errors. Pediatr Clin North Am. 2006;53:1091-1104.
(For non-journal subscribers, an additional fee may apply
for full text articles.) |
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In
their 1999 report "To Err is Human," the Institute of Medicine recommended
that to improve the quality and safety of care, adverse events resulting
from medical error should be disclosed to patients and their families.
In this 2006 publication, Matlow et al examined medical error disclosure
in several contexts, and provided summary consensus recommendations.
Historically, the practice of advising physicians to "guard what
is said to the patient" stems from a rise in malpractice cases in
the early 20th century. More recently, however, this advice has been
called into question in the face of ethical frameworks emphasizing
physicians’ professional and fiduciary duties, respect for patients’ autonomy,
and the inherent trust in a doctor-patient relationship. The authors
report on medico-legal experience and mock trial studies, which suggest
that proactive disclosure may lead to claims avoidance and more favorable
outcomes (although they note that more research is needed in these
areas). The researchers report that patients’ (and parents’) preference
for full disclosure when a medical error has occurred is universal,
with expectations of explicit statements that the error in fact occurred,
what the error was, why it occurred, how it will be prevented from
recurring, and an apology. Reported physician barriers to disclosure
include: difficulty in admitting mistakes, fear of implicating others,
possibilities of legal action, and the blame felt by physicians when
an error has occurred. The authors note that Harvard University,
the Veterans Health Administration, and JCAHO (among others) have
provided outlines of: a) events that should be disclosed/communicated
to the patient; b) how they should be communicated and in what contexts
(what, who, when and where); c) documentation of the medical error;
and d) support of error victims. |
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Kaldjian
LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE. Disclosing
medical errors to patients: attitudes and practices of physicians
and trainees. J Gen Intern Med. 2007;22:988-996.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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Kaldjian
et al designed a cross-sectional survey of 538 faculty, resident and
student physicians – pediatricians comprised 46% of faculty and 27%
of residents – asking participants if they had ever a) made “a mistake
that prolonged treatment/caused discomfort” or b) “caused disability/death,” and
their disclosure of it. Participants were also presented with a hypothetical
error vignette (with major, minor, or no harm response choices), and
further, were asked to detail their beliefs about disclosure according
to a taxonomy of facilitating and impeding attitudes. Forty-seven percent
of respondents reported having made at least one minor or major error:
15% of faculty and residents reported a minor error that they disclosed
and one they did not; 1% reported a major error they disclosed and one
they did not; and 10% reported non-disclosure of an error due to legal
liability (with 6% of faculty reporting attorney advice not to disclose).
The researchers found that both actual and hypothetical disclosures
were associated with feeling an obligation to disclose, as well as the
belief that the decision to disclose did not depend on whether or nor
it would help the patient. Actual disclosure alone was associated with
the belief that disclosure alleviates guilt, while hypothetical disclosure
alone was associated with the belief that disclosure is right (even
at personal cost) because the respondent would want it and because it
strengthens patient trust. Faculty were found more likely than trainees
to disclose errors resulting in major or no harm. Of particular note,
pediatricians were more likely than other physicians to disclose hypothetical
error resulting in major or no harm and less likely to believe disclosure
depends on if the information will help the patient. Those respondents
believing forgiveness to be important were more likely to disclose hypothetical
error with minor harm but were less likely to have disclosed an actual
error with major harm. Further, litigation experience was associated
with increased actual and hypothetical disclosure, although being a
defendant was associated with actual non-disclosure of a disabling or
fatal error. |
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Garbutt
J, Brownstein DR, Klein EJ, et al. Reporting and disclosing
medical errors: pediatricians' attitudes and behaviors. Arch
Pediatr Adolesc Med. 2007;161:179-185.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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In
an exploration of pediatricians’ attitudes toward and experience with
reporting errors to hospitals and disclosure of errors, Garbutt et al
performed an anonymous cross-sectional survey of 439 university-affiliated
hospital and community pediatricians (50% in private practice) and 118
pediatric residents from St Louis and Seattle. Ninety-three percent
of participants had been involved in a medical error. Pediatricians
were asked about their beliefs and behaviors related to reporting, disclosure
and collegial discussion of errors, their experience with formal and
informal reporting of errors, features of systems that would increase
willingness to report errors, and their beliefs and experiences regarding
disclosure (eg, types of errors that should be disclosed, barriers to
disclosure, and personal experience). While respondents endorsed reporting
errors to the hospital (97%, serious; 90%, minor; 82%, near miss), only
39% thought that current error reporting systems were adequate. Most
had used formal (‘incident report’ – 65%) or informal (‘telling a supervisor/senior
physician’ – 47%/38%) methods of reporting errors, and 72% had discussed
errors with colleagues. Respondents endorsed disclosing errors to patients'
families (99% serious; 90% minor; 39% near miss), and many had done
so (36% serious, 52% minor). Some respondents reported multiple barriers
to disclosure, as well as a reduced likelihood to disclose an error
if they perceived the family would not understand, was unaware, or would
not want to know. Residents were more likely than attending physicians
to believe that disclosing a serious error would be difficult (96% vs
86%) and to want specific disclosure training (69% vs 56%). The authors
recommend formal and experiential training for residents to further
educate them in open communication about errors |
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Hobgood
C, Tamayo-Sarver JH, Elms A, Weiner B. Parental preferences
for error disclosure, reporting, and legal action after medical
error in the care of their children. Pediatrics. 2005;116:1276-1286.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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In
a study of parental preferences for error disclosure and reporting,
a convenience sample of 400 parents of children presenting to a tertiary
care academic emergency department were presented with 4 short vignettes
of hypothetical events occurring to their children. These included:
- medication errors
- 7-year-old with cancer chemotherapy overdose and subsequent
lifelong dependence on dialysis
- 8-year-old with seizure and diazepam overdose with
subsequent recovery and no long-term problems
- failure to diagnose
- 6-year-old with bacterial meningitis and subsequent
permanent hearing loss
- 5-year-old with sore throat subsequently diagnosed
as strep throat leading to treatment and full recovery
The authors found that parents
judged 54% of the scenarios as severe; 99% wanted disclosure; 39% wanted
the error reported to a disciplinary body; and 36% were less likely
to seek legal action if the error was disclosed by the physician. Of
note is that African-American parents in the study were found more likely
to judge an event as severe (62% vs 49%) and to choose to have an error
reported to a disciplinary organization (50% vs 33%). This study supports
that: a) parents universally want disclosure of pediatric medical errors
regardless of severity, b) disclosure may reduce parental likelihood
of seeking legal action except in severe errors, and c) increased (perceived)
severity of medical errors is associated with increased desire for reporting
to a disciplinary agency. |
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CASE
STUDY:
MEDICAL ERROR RESULTING IN DEATH |
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Keatings
M, Martin M, McCallum A, Lewis J. Medical errors: understanding
the parent's perspective. Pediatr Clin North Am. 2006;53:1079-1089.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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This
2006 case study describes events occurring prior and subsequent to the
death of Claire Lewis, an 11-year-old patient who died 3 days postoperatively
in the Hamilton Health Sciences system, and includes discussion of associated
system issues regarding the management of disclosure. After excision
of a craniopharyngioma, the patient was transferred to an ICU in a different
hospital (for pediatric care), but with a delay in transfer of her perioperative
medical records. ICU management (without the records) led to fluid overload,
hyponatremia, and catastrophic cerebral edema that caused her death.
Review of the case revealed (among other issues) the need for staff
refresher training in pediatric-specific postoperative care of craniopharyngioma
(a relatively rare procedure), and the use of checklists and protocols.
Initial failure by the physician and risk management team reviewing
the case to address critical points (and to disclose to the family)
led to a 4-month delay in senior management awareness of the problems,
which contributed to distrust and anger by the family. Claire’s father,
a nurse within the system, informed senior management of the system
problems, which led to a subsequent decision for full disclosure and
recommendations to implement reporting mechanisms. However, a similar
death occurring within 1 year revealed that the recommended changes
had not been made, resulting in additional
re-evaluation of how system changes
were implemented and followed up. Subsequent full disclosure, apology,
reconciliation with the family, and recommendations (plus follow up)
for system, knowledge, and education changes were accomplished and are
described by the authors. |
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FACTORS
PROMOTING MALPRACTICE CLAIMS |
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Hickson
GB, Clayton EW, Githens PB, Sloan FA. Factors that prompted
families to file medical malpractice claims following perinatal
injuries. JAMA. 1992;267:1359-1363.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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Hickson
et al performed a combined structured and open-ended telephone-administered
questionnaire of families in Florida who had closed malpractice claims
regarding infants who suffered permanent minor injuries (loss or damage
to organs) or more, including death. Of 368 eligible families, 35% participated.
The responses elicited provided information about medical care, physician-family
communication, cost of injury, compensation, legal, and socio-demographic
factors.
When asked about reasons for
filing a claim, respondents most frequently reported (multiple reasons
included):
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influence
from someone outside of the family (over half of those being physicians) |
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the
need to pay for long-term care |
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(24%) |
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the
realization that the physician failed to be completely honest |
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(20%) |
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the
realization that the child would have no future |
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(20%) |
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the
need to “find out what happened” |
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(19%) |
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a
desire to deter the physician from further malpractice or for revenge |
Most
respondents complained about physician-family communication, reporting
that the physician: would not communicate (32%), would not listen (13%),
misled them (48%), and never informed them that their infant would have
permanent problems or might die (70%). The authors’ note that physicians’ difficulties
in communicating may arise from underestimation of parents’ information
needs, parents’ need to review the same issues several times, and/or
from their own personal discomfort. Recommendations included: contemporaneous
records of what is said to parents and increased efforts to improve
communication, including education of trainees. |
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THE
ELEMENTS OF ERROR DISCLOSURE |
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Fein
SP, Hilborne LH, Spiritus EM, et al. The many faces of error
disclosure: a common set of elements and a definition. J
Gen Intern Med. 2007;22:755-761.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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In
a qualitative analysis of focus group transcripts from 5 academic medical
centers, (including hospital administrators, physicians, nurses and
residents), Fein at al presented participants with a standard definition
of medical error, followed by a hypothetical scenario of an inpatient
error. Participants were asked if there should be disclosure, and if
they believed the provider would disclose it. Providers were asked what
steps and words they would use, while administrators were asked what
they would expect to hear in a disclosure.
Transcript analysis revealed
6 elements of disclosure desired by patients:
- admission
of an error
- discussion
of the events of the error
- linkage
of the error to an effect
- first
effect of the error
- link between the error and any harm sustained, and
- explanation
of the harm (and if it was communicated)
Five distinct types of disclosure
were derived, based on the presence or absence of each of the above
elements:
- Full
disclosure
(all elements present)
- Partial
disclosure: connect-the-dots
(discussion of events
and explanation of harm)
- Partial disclosure: mislead
(connect-the-dots with
obfuscation of linkage of error to harm)
- Partial
disclosure: defer
(connect-the-dots with
deference of linking error to harm)
- Nondisclosure
(no elements present)
The authors provide examples
and wording of each type of disclosure with regard to how it matches
or does not match patient expectations, along with discussion of how
this information may help create realistic guidelines for disclosure. |
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| Accreditation
Statement — back
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Physicians
The Johns Hopkins
University School of Medicine is accredited by the Accreditation
Council for Continuing Medical Education (ACCME) to provide continuing
medical education for physicians.
Nurses
The Institute for
Johns Hopkins Nursing is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center's Commission
on Accreditation.
Respiratory
Therapists
Respiratory therapists
should visit
this page to confirm that AMA PRA Category 1 Credit(s)TM is
accepted toward fulfillment of RT requirements. |
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| Credit
Designations — back
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Physicians
eNewsletter: The Johns Hopkins University School
of Medicine designates this educational activity for a maximum of
1.0 AMA PRA Category 1 Credit(s)TM. Physicians
should only claim credit commensurate with the extent of their participation
in the activity.
Podcast: The Johns Hopkins University School of
Medicine designates this educational activity for a maximum of 0.5 AMA
PRA Category 1 Credit(s)TM. Physicians should only
claim credit commensurate with the extent of their participation
in the activity.
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eNewsletter: This 1.0 contact hour Educational Activity
(Provider Directed/Learner Paced) is provided by The Institute for
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hour or a total of 12.0 contact hours for the twelve newsletters
in this program.
Podcast: This 0.5 contact hour Educational Activity
(Provider Directed/Learner Paced) is provided by The Institute for
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hours or a total of 3.0 contact hours for the six podcasts in this
program.
Respiratory
Therapists
For United States: Visit
this page to confirm that your state will accept the CE Credits
gained through this program.
For Canada: Visit
this page to confirm that your province will accept the CE Credits
gained through this program. |
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| Post-Test
— back
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| To
take the post-test for eNeonatal Review you will need to visit The
Johns Hopkins University School of Medicine's CME website or The
Institute for Johns Hopkins Nursing or download a PDF of the
post-test from the issue itself for Pharmacy. If you have already
registered for another Hopkins CME program at these sites, simply
enter the requested information when prompted. Otherwise, complete
the registration form to begin the testing process. A passing grade
of 70% or higher on the post test/evaluation is required to receive
CME/CNE credit. |
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of Responsibility — back
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| The
Johns Hopkins University School of Medicine and The Institute for
Johns Hopkins Nursing take responsibility for the content, quality,
and scientific integrity of this CME/CNE activity. |
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| Target
Audience — back
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| This
activity has been developed for neonatologists, NICU nurses and
respiratory therapists working with neonatal patients. There are
no fees or prerequisites for this activity. |
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| Learning
Objectives — back
to top |
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At
the conclusion of this activity, participants should be able to:
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Identify
the key elements of complete error disclosure |
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Discuss
the currently identified barriers to error disclosure |
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Explain
the relationship between error disclosure and litigation |
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| Internet
CME/CNE Policy — back
to top |
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The
Office of Continuing Medical Education (CME) at The Johns Hopkins
University School of Medicine (SOM) is committed to protect the
privacy of its members and customers. The Johns Hopkins University
SOM CME maintains its Internet site as an information resource and
service for physicians, other health professionals and the public.
Continuing Medical
Education at The Johns Hopkins University School of Medicine and
The Institute for Johns Hopkins Nursing will keep your personal and
credit information confidential when you participate in a CE Internet
based program. Your information will never be given to anyone outside
The Johns Hopkins University program. CME/CE collects only the information
necessary to provide you with the service you request. |
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| Faculty
Disclosure — back
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It
is the policy of the Johns Hopkins University School of Medicine
that the faculty and provider disclose real or apparent conflicts
of interest relating to the topics of this educational activity,
and also disclose discussions of unlabeled/unapproved uses of drugs
or devices during their presentation(s). Johns Hopkins University
School of Medicine CME has established policies in place that will
identify and resolve all conflicts of interest prior to this educational
activity. Detailed disclosure will be made in each issue of the
newsletter and podcast. The Course Directors reported the following:
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Edward
E. Lawson, MD has indicated a financial relationship
of grant/research support from the National Institute of Health
(NIH). He also receives financial/material support from Nature
Publishing Group as the Editor of the Journal of Perinatology. |
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Christoph
U. Lehmann, MD has indicated no financial relationship
with commercial supporters. |
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Lawrence
M. Nogee, MD has received grant support from the NIH. |
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Mary
Terhaar, DNSc, RN has indicated no financial relationship
with commercial supporters. |
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Robert
J. Kopotic, MSN, RRT, FAARC has indicated a financial
relationship with the ConMed Corporation. |
Guest
Authors Disclosures |
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| Disclaimer
Statement — back
to top |
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| The
opinions and recommendations expressed by faculty and other experts
whose input is included in this program are their own. This enduring
material is produced for educational purposes only. Use of The Johns
Hopkins University School of Medicine name implies review of educational
format design and approach. Please review the complete prescribing
information of specific drugs or combination of drugs, including
indications, contraindications, warnings and adverse effects before
administering pharmacologic therapy to patients. |
|
© 2007
JHUSOM, IJHN, and eNeonatal Review
Created by DKBmed. |
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COMPLETE
THE POST TEST
Step
1.
Click on the appropriate link below. This
will take you to the post-test.
Step
2.
If you have participated in a Johns Hopkins
on-line course, login. Otherwise, please register.
Step
3.
Complete the post-test and course evaluation.
Step
4.
Print out your certificate.
Respiratory Therapists
Visit
this page to confirm that your state will accept the CE Credits gained
through this program or click on the link below to go directly to the post-test.
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