EXECUTIVE SUMMARY

Medical errors or apologies were infrequently documented even if patients were seriously harmed, found a recent study.

  • The study was conducted prior to enactment of the Massachusetts law requiring disclosure of unanticipated outcomes with a significant medical complication.
  • Disclosure documentation has presumably increased significantly after the 2012 law was passed mandating this practice.
  • Safety culture improved after disclosure training was provided to physician leaders.

Very few disclosures of medical errors or apologies to the patient or relatives were documented in medical records, found a recent analysis of malpractice claims.1

To provide preliminary estimates of incident disclosure behaviors on medical malpractice claims, researchers analyzed data on 434 claims between 2012 and 2013. Rates of disclosure did not increase between 2011 and 2013, despite efforts to encourage disclosure of adverse events during this time period.

“Frequently, it’s very difficult to know whether an error occurred or not. So timing also plays a part in this,” says Luke Sato, MD, one of the study’s authors. Sato is senior vice president and chief medical officer at CRICO, the patient safety and medical malpractice insurer for the Harvard medical community, and an assistant clinical professor of medicine at Harvard Medical School in Boston.

Of the 434 medical malpractice claims, only 20 medical errors had been disclosed to the patient at the time of the error; 26 were followed by disclosure and apology. Of the disclosed errors, 26% led to an adverse reaction, and 17% were fatal. No apology statement was issued in 55% of medical errors classified as high severity. Volume of malpractice claims also remained unchanged.

The motivation for the study was to see how frequently the disclosure process was documented when a malpractice claim occurred, says Sato.

Massachusetts’ Health Payment Reform Act, which became effective in November 2012, requires disclosure of unanticipated outcomes with a significant medical complication. However, at the time the study was conducted, there was no formal disclosure process. “Therefore, even if an error was disclosed, it was rarely documented in the medical record. Our findings were not unexpected,” says Sato.

The researchers expected the rate of error disclosure to be very low, based on the timing of the state’s law. “Given the timing of this, we were not at all surprised the practice was not ubiquitous,” says Sato. “If we were to repeat the study and still see somewhat low incidents of disclosure now, that would be problematic.”

There is growing evidence to support early disclosure of errors. Every error should be evaluated for whether it needs to be disclosed, says Sato.

“The nuances are challenging. We are currently learning how best to do it,” says Sato. “A tremendous amount of learning has been accumulated over the past five years.”

At Brigham and Women’s Hospital, providers encourage patients to seek legal counsel in some cases, says Sato. This saves time and money for everyone involved. In some cases, the attorney discourages the patient from moving forward with a frivolous complaint. On the other hand, valid cases are resolved more quickly with early discussion and transparency.

“Resolution of those cases tends to be a lot smoother, and more compassionate for the patient’s family and for the caregivers involved,” says Sato.

Training Is Helpful

Error disclosure, teamwork, and safety culture all improved over a three-year period during which disclosure training was provided to key faculty at the Austin-based University of Texas Health System.2

“If a healthcare organization does not have a disclosure culture, it is possible that providers will be less likely to disclose errors and patients will be less likely to know about issues that have impacted their healthcare,” says Eric J. Thomas, MD, MPH, one of the study’s authors.

The intervention did not involve a large number of clinicians at the institutions. Therefore, the improvement in disclosure culture was a pleasant surprise.

“But the clinicians we chose were leaders, and they likely impacted others through additional training,” says Thomas, a professor of medicine at the University of Texas Houston Medical School and director of the UT Houston-Memorial Hermann Center for Healthcare Quality and Safety.

More clinicians perceived their work environment as being supportive of disclosing errors after the training. Self-reported likelihood to disclose errors also improved.

“The results are encouraging in that they indicate that specific training on error disclosure was associated with intent to disclose an error,” says Jason Etchegaray, PhD, the study’s lead author and a senior behavioral and social scientist at the Rand Corporation in Santa Monica, CA.

This is an important first step in changing behavior. “Ideally, a follow-up study would demonstrate a specific relationship between error disclosure training and actual disclosure behavior from providers,” says Etchegaray.

REFERENCES

  1. Giraldo P, Sato L, Castells X. The impact of incident disclosure behaviors on medical malpractice claims. J Patient Saf 2017 Jun 30. doi: 10.1097/PTS.0000000000000342. [Epub ahead of print].
  2. Etchegaray JM, Gallagher TH, Bell SK, et al. Error disclosure training and organizational culture. Agency for Healthcare Research and Quality, Rockville, MD, 2009. Content last reviewed August 2017. Available at: http://bit.ly/2zyCdyL. Accessed Nov. 10, 2017.

SOURCES

  • Jason Etchegaray, PhD, Senior Behavioral and Social Scientist, Rand Corporation, Santa Monica, CA. Phone: (310) 393-0411, ext. 7648. Email: jetchega@rand.org.
  • Luke Sato, MD, Department of Medicine, Harvard Medical School, Boston. Phone: (617) 679-1549. Email: lsato@rmf.harvard.edu.
  • Eric J. Thomas, MD, MPH, Director, UT Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston. Phone: (713) 500-7958. Email: eric.thomas@uth.tmc.edu.