To tell the truth: Disclosing errors not always easy for caregivers

Patients need to know when mistakes are made, physicians urge

When asked where they feel safer, respondents to a national poll ranked airline travel and their own workplace safer than the hospital, clinic, or physician office. Even more disturbing, 42% of adults surveyed said they or a relative or friend have suffered from a medical error. Those results are from a first-of-its-kind survey on patient safety in health care commissioned by the National Patient Safety Foun-dation in Chicago. Started in July 1997, the foundation has developed a set of goals and recommendations for moving toward an error-free health care environment. (For more on the foundation, see story, p. 18.)

But not all perceptions are as foreboding. Overwhelmingly, with a 95% response rate, respondents cited their personal physician as the one individual who can have a positive effect on their safety during care. Nurses, pharmacists, and physician office staff — other health care professionals who patients encounter directly — rank nearly high as physicians. Faceless hospital administrators and government officials, however, ranked toward the bottom of the scale. (Patients’ ideas of the main causes of medical mistakes are outlined in the chart, p. 15, top.)

Interestingly, patients ranked themselves second as having an effect on their safety. Patients feel an obligation to report any allergies, notify physicians of other medication they may be taking, and conduct their own investigations of a physician’s record of malpractice, according to survey results. (For other precautions patients feel are necessary to ensure safety, see chart, p. 15, center.)

The survey, titled Public Opinion of Patient Safety Issues, coincides with recent articles urging physicians to disclose medical mistakes to their patients. And ethics committees, not surprisingly, are caught in the middle of the tug of war between urging physicians to tell the truth and assuring patients they are receiving the best possible care.

When designing a program to foster disclosure of mistakes to patients, it’s best to start with physicians, says Martin J. Hatlie, JD, executive director of the National Patient Safety Founda-tion. "Patients usually invest emotionally in people who are providing direct care, and if the outcome is not what they expected or there’s an accident, they want to hear if from the nurse or physician who cares for them rather than someone else within the institution," he adds. (For survey respondents’ suggestions, see p. 15, bottom. For more suggestions on eliminating mistakes, see stories, pp. 16-18.)

Although risk managers usually get involved in a situation after a caregiver has reported a mistake, Hatlie says patients often feel confused and abandoned "because the physician or nurse is told not to have any more discussion with the patient. What was a nurturing, care-driven relationship between the caregiver has been turned into more of an adversarial relationship."

One solution that ethics committees can work on is to foster a different climate within the hospital. "You want an environment that conveys to workers that coming forward with a mistake — whether it was personal or a system error — is better for the hospital than burying the problem internally. A work culture that penalizes people rather than the system doesn’t help obtain a safe system. It’s a hard thing to accomplish because there’s a natural human tend- ency to want to blame someone or something," Hatlie explains.

Other industries, such as airline travel and automobile manufacturing, focus on eliminating mistakes by improving the system, not punishing the person. This has not been done in health care, Hatlie says. Instead, those responsible for a mistake hide it, and the underlying system weakness goes unnoticed.

Not just a physician issue

Don’t stop with physicians when promoting disclosure of medical mistakes, urges Albert Wu, MD, associate professor of Health Policy and Management at Johns Hopkins University in Baltimore. "It’s not just a physician issue, it should involve everyone who provides patient care," he explains. (The chart on p. 16 shows where patients would go to report a medical mistake.)

One thing to keep in mind, however, is that sometimes it becomes unclear who is communicating with the patient. If the patient is more comfortable with the physician, for example, it would be all right for the physician to discuss a mistake that occurred while a nurse was providing care," he explains.

Wu, along with other researchers, recently urged physicians to disclose mistakes in an article in the Dec. 1997 issue of the Journal of General Internal Medicine. The primary reason for caregivers not wanting to disclose mistakes to patients is shame, he says. "Embarrassment and shame are the primary motivators of this type of behavior. And then there’s the falsely held belief that it’s better not to disclose a mistake because of the threat of potential lawsuits."

But the risks of lawsuits are very real indeed, Hatlie says. He stresses that caregivers all too often are warned by risk managers that statements made to patients can be used as an admission of a mistake. "The big problem is getting physicians, nurses, and an institution to feel comfortable about talking. Apologies are appropriate at times, but other times you may not want to admit to anything until all the facts are in, so it’s a tough balancing act."

Not disclosing a mistake could damage the patient-physician relationship. "The patient may naturally be upset and angry if the mistake had significant adverse effects, but the physician can begin to negotiate a settlement, or the patient may simply appreciate the honesty and truth," Wu says.

When to tell is a gray area

Deciding when to notify the patient is another gray area. "You don’t want to mention a mistake to a patient right before beginning a surgical procedure, but you also don’t want them to accuse you of covering it up from them," he explains.

A written policy on reporting medical mistakes may not be the magic wand that eliminates the need to disclose them, Wu says "That should be left up to each individual hospital, but education and letting staff learn from how previous mistakes were handled is probably the best method of eliminating mistakes."

Johns Hopkins conducts role-playing sessions with physicians and staff on how to disclose a mistake to a patient. "We run through scripts where a mistake is disclosed, and the person disclosing the mistake may have an idea of how the patient might react, but in the heat of the moment it’s hard to tell how they’ll [the patient] react," he says.

Ethics committees can play a vital role in education, however, because it is rarely a part of formal education. "The ethical obligation to disclose a mistake is not covered in the medical school curriculum, and very few instructors address it," adds Wu. He suggests educating staff by going over case histories and providing examples of how a particular episode was handled.

Conferences, symposia, and seminars also are great educational resources. "Some hospitals include the subject in orientation materials so physicians and staff know that the hospital encourages open communication with patients."

Not all medical mistakes require disclosure, however. Both Wu and Hatlie agree that a trivial mistake, especially when the patient suffers no adverse outcome, should not be disclosed. "That could lead to more apprehension and doubt for the patient," Wu says.