Clinical Communication

Disclosure After Adverse Medical Outcomes: A Multidimensional Challenge

Journal of Clinical Outcomes Management. 2019 September;26(5):213-218

Author(s):

References

1. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. National Academies Press; 1999.

2. Gibson R, Singh JP. Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans. Washington, DC: Lifeline Press; 2003.

3. Rathert C, Phillips W. Medical error disclosure training: evidence for values-based ethical environments. J Bus Ethics. 2010;97:491-503.

4. Wu AW, Cavanaugh TA, McPhee SJ, et al. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med. 1997;12:770-775.

5. Gallagher TH, Waterman AD, Ebers AG, et al. Patients’ and doctors’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001-1007.

6. The Patient Safety and Quality Improvement Act of 2005 (PSQIA); Public Law 109-41, 119 Stat. 424-434, which amended the Public Health Service Act.

7. Banja J. Moral courage in medicine—disclosing medical error. Bioethics Forum. 2001;17:7-115

8. Boothman R, Imhoff SJ, Campbell DA. Nurturing a culture of patient safety and achieving lower malpractice risk through disclosure: Lessons learned and future directions. Front Health Serv Manage. 2012;28:13-27.

9. Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153:213-221.

10. Mello MM, Boothman RC, McDonald T, et al. Communication and resolution programs: the challenges and lessons learned from six early adopters. Health Affairs. 2014;33:20-29.

11. Marx D. Patient Safety and the Just Culture: A Primer for Health Care Executives. New York, NY: Trustees of Columbia University; 2001.

12. AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; May 2016.

13. O’Connell D, White MK, Platt F. Disclosing unanticipated outcomes and medical errors. J Clin Outcomes Manag. 2003;10:25-29.

14. Berlinger N. After Harm: Medical Error and the Ethics of Forgiveness. Baltimore, MD: Johns Hopkins University Press; 2005.

15. O’Connell D, Reifsteck SW Disclosing unexpected outcomes and medical error. J Med Prac Manag. 2004;19:317-323.

16. Robson R, and Pelletier E. Giving back the pen: Disclosure, apology and early compensation discussions after harm in the healthcare setting. Healthc Q. 2008;11(3 Spec No.)85-90.

17. Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131:963-967.

18. Ding XP, Wellman HM, WangY, et al. Theory-of-mind training causes honest young children to lie. Psychol Sci. 2015;26:1812-1821.

From The Communication in Healthcare Group, Seattle, WA.

Abstract

Objective: To review established approaches to disclosure and resolution following adverse medical outcomes and highlight barriers that may hinder universal implementation of effective disclosure/resolution practices.
Methods: An overview of established approaches to disclosure and resolution of adverse medical outcomes is presented.
Results: Clinicians must be equipped to manage situations where adverse medical outcomes occur even though the care provided was reasonable, within the standard, as well as in situations where preventable problems in the care provided were likely the cause of patient harm. Established approaches that have proven useful for investigating, disclosing, and resolving situations, captured in the acronyms AIDR, ALEE, and TEAM, can assist clinicians in the disclosure and ultimate resolution of these 2 types of situations.
Conclusion: Health care organizations with a solid commitment and a reliable structure for ensuring adherence to full disclosure and fair resolution of adverse outcomes have demonstrated sustainable progress in ethically and effectively resolving situations where patients are harmed by medical care.

Keywords: safety; medical error; adverse outcomes; resolution; communication.

Much has been learned over the 20 years since the Institute of Medicine’s (IOM) report To Err Is Human¹ was published. At the time it was published, the IOM report made it clear that only a minority of preventable patient harms were being acknowledged, investigated, and reported. In the face of adverse outcomes “dissemble, deny, and defend” was a common strategy of many clinicians, institutions, and liability carriers.² The health care system appeared to place a priority on protecting itself from reputational and financial harm over the rights of injured patients to be given an accurate understanding of what had happened in their care and to pursue restitution, if appropriate.^3-5

The emerging quality improvement movement was accompanied by calls for increased patient advocacy. This included the goal of greater transparency and more timely and equitable resolutions with patients who have been harmed by problems in care. Health care systems pressed for confidentiality protections in exchange for increased focus on quality improvement.⁶ Applying medical ethics of autonomy, no-maleficence, beneficence, and justice initially took a backseat, as risk management was given priority.⁷ Insurance carriers have no ethical obligation, and a clear disincentive, to assure that harmed patients are fully informed and offered restitution. Some self-insured health systems, however, began experimenting with more proactive and transparent approaches to disclosure and resolution. In contrast to the often-reported fear of a liability explosion, they reported reduced claims and suits, shorter time to resolution, and reduced overall financial cost,^8-10 providing some evidence that perhaps greater openness could work after all.

But for providers and staff to allow transparency and candor to become the norm, institutions needed to create a more “just culture” for managing errors. Individual impairment or willful disregard of safe practice would need to be handled differently from the slips and lapses that more often contributed to preventable harm.¹¹ For example, the nurse who was inadequately oriented to the equipment on an unfamiliar unit where she was asked to work a double shift due to a staffing shortage should not be held as accountable as an employee who knowingly violated agreed upon safe practices, even though patient harm resulted in each situation. It became clear that patient harm was usually the result of multiple factors involving individuals, communication, procedures, systems, and equipment. Blaming and disciplining individuals at the sharp end would not reliably reduce adverse outcomes.

Since the 1999 IOM report, we have developed general agreement on best practices for investigating, disclosing, and resolving situations where patients are harmed by medical care.^12,13 This article reviews the perspectives and practices that appear necessary for effective disclosure and resolution after an adverse outcome and highlights barriers to reliably enacting them in practice.