Use proven strategies for error disclosure to patients

Answer the questions foremost on patients' minds

A growing number of organizations are disclosing errors to patients, but this can be disastrous if handled poorly.

"We need to train physicians and other health care professionals how to do this well," says Gregg Meyer, MD, Boston-based Massachusetts General Hospital's senior vice president for quality and safety. "This is a growing trend, but we need to prepare our workforce, just like we would for any critically important procedure or intervention."

At Massachusetts General, situation management training prepares senior clinical and administrative staff to serve as disclosure "coaches." Disclosure is built into the patient care assessment process. "We are seeing this happen much more routinely," says Meyer. "This is a good development for patients and providers."

At Virginia Mason Medical Center in Seattle, a policy requires the attending physician to disclose unanticipated outcomes, says Cathie Furman, senior vice president of quality and compliance. "We do not differentiate between errors and unanticipated outcomes," she says.

The policy was developed after a provider tried to disclose an error, but did not have the skills and handled it less than optimally, says Furman.

Physicians are given a two-and-a-half-hour workshop on communication of unanticipated outcomes, given by a trained consultant. "We have a specific role titled a 'situation facilitator' who has received additional training and coaching by the same consultant," says Furman.

The situation facilitators come from multiple disciplines and include nursing leaders and quality professionals. "Their role is to provide coaching to an attending physician who has not had much experience with disclosure," she says.

The facilitator can be physically present when the error is disclosed or can coach the physician on the phone prior to disclosure, says Furman.

Good communication between clinical staff and patient/family is important for all aspects of care, says Donald Kennerly, MD, vice president of patient safety and chief safety officer at Baylor Health Care System in Dallas. The hospital system won the Leapfrog Patient-Centered Care Award in 2007 for its patient-centered practices, including having a policy in place for disclosing medical errors to patients and their families.

When an unexpected outcome takes place, whether or not it involves an error, the clinical team is expected to let the patient and family know what is happening and what is being done about it.

"When a serious outcome is encountered that is unexpected, we continue to emphasize the value of timely communication with the patient and family about what we do know at the time," says Kennerly. The staff also commit to follow-up communications when more information is identified as the result of any investigation that might take place. The patient's physician is most often the best person to make these disclosures, says Kennerly. "When that is not possible, then a hospital executive will do this," he says.

In either case, these professionals have "just in time" training given by risk management to help them anticipate the type of questions they are going to receive from the patient and family.

Answer these questions

The key to success is to answer the questions that are always on patients' minds, says Kennerly:

  • What happened? "If this isn't clear at the time, it is very effective to provide some information to the patient and commit to returning when more information is known," says Kennerly.
  • What does this event mean, if anything, to my health? What can I expect in terms of any change in care or expected outcome?
  • A commitment on the hospital's part to understand why the event happened, even if this information is not shared with the patient, and to use this information to try to prevent future similar events from happening.

Any time there is a serious adverse event, an investigation takes place. A hospital expert in quality or patient safety reviews the chart, talks to other health care professionals, and determines the specific things that took place before and during the event. "The patient and family rarely want to know all of this," says Kennerly. "So the disclosing professional will summarize the more important aspects of the situation."

If the event involves errors and/or inadequate systems of care, an apology is often both appropriate and very important to the patient. "It is controversial, however, since some states allow an apology to be used in court as an implied acknowledgement of responsibility," says Kennerly.

Improve systems

Quality, safety, and risk management professionals at Baylor's hospitals are involved with disclosure of an adverse event in several ways. First, they are at the center of the investigation to understand the facts of the incident. This information is communicated to whomever will do the disclosure, and that individual is usually coached on the most effective way to disclose what will be important for patients to know.

"Second, the quality professional's role is to begin the process of organizational learning to determine why the adverse event took place, and what can be done to prevent it from recurring in the future," says Kennerly.

As part of the investigation, the quality professional will try to understand why the event occurred by checking into potential contributing factors such as a poorly designed process of care, communication problems, a high workload, equipment problems, ambiguous policies, training issues, or distracting events occurring at the same time.

The information is then used to design and implement improved processes that together constitute an improved system. "Since the vast majority of adverse events are due to suboptimal systems, the improvement of the system is key to improving care in a durable way," says Kennerly.

[For more information, contact:

Cathie Furman, Senior Vice President, Quality and Compliance, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA 98101. Phone: (206) 223-6182. E-mail: cathie.furman@vmmc.org.

Donald Kennerly, MD, Vice President, Patient Safety and Chief Patient Safety Officer, Baylor Health Care System, 8080 N. Central Expressway, Suite 500, Dallas, TX 75206. Phone: (214) 265-3621. E-mail: donaldk@baylorhealh.edu.

Gregg Meyer, MD, Senior Vice President, Quality and Safety, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114. Phone: (617) 724-8098. E-mail: gmeyer@partners.org.]