Medical Errors

Medical Errors  1-800-23-ERROR  To report medical errors in confidence to the Institute for Safe Medical Practices www.ismp.org

How to Tell Patients about Errors

DISCLOSING MEDICAL ERRORS

—Leah J. Heimbach, JD, RN, General Counsel, West Virginia University Hospitals, Incorporated, Morgantown Benefits of disclosure for patient: patient may consent to further treatment, thus preventing further harm; may prevent patient from panicking Consequences of disclosure for patient: patient/family angry, anxious; confidence in physician’s skills impaired; desire to sue physician (disclosure decreases amount of money paid out) Benefits of disclosure for physician: relief; ability to have more honest and open relationship with patient; patient may respect physician for admitting mistake and trust physician to continue care; physician less likely to be sued; physician learns from mistake Consequences of disclosure for physician: disillusionment about self and system; loss of privileges; conduct may be reported to national data bank; peers may not refer patients; loss of medical license; licensing agencies and peer review committee “will treat you less harshly if you are open and receptive to [the process]” How to disclose: think it through, and put yourself in patient’s shoes (ie, what would I want and need?); consider timing; tell patient, even if patient unconscious (“you don’t know what they hear and don’t, or remember and don’t”) Who to tell, in order of priority: patient and anyone else patient wants present; if patient unconscious, tell his or her medical power of attorney; if no medical power of attorney named, tell health care surrogate; disclosing to anyone else is violation of Health Insurance Portability and Accountability Act (HIPAA); “‘next of kin’ means nothing legally”; if no health care surrogate named and no family member willing or able to act as health care surrogate, decision about patient’s care under auspices of Department of Health and Human Services (Adult Protective Services or Child Protective Services) Disclosing Preparation: make sure there are enough chairs; ensure privacy as much as possible; ensure lighting appropriate; shut door; be prepared to take notes; be cognizant of proximity to door in case person reacts violently and you need to leave; may want to bring someone with you Beginning: everyone seated; sit close to person (be on equal level with patient or family member); determine what they already know; ask how much detail they want; write notes unless not comfortable doing this or patient or family objects; opening phrases may include, “I’m afraid I’ve got some bad news for you,” or “this is difficult for me to say,” or “I’ve made a mistake”; get to point and let them react; maintain eye contact Middle: if patient starts “tearing up” and looks away, stop talking and let patient absorb what has been said; may touch patient’s arm or hold hand if appropriate to circumstances (if patient pulls away or reacts, do not attempt it again); use common sense; ask if what you are saying makes sense; repeat as needed; use simple terms; expect anger, anxiety, crying; give them opportunity to express themselves Closure: “a patient wants to hear anything that sounds like an apology even if it’s not an apology”; do not admit fault or liability; saying, “I’m sorry this happened,” or “I’m sorry you were hurt” is not admission of liability; be prepared to deal with questions; if they want to know names of those at fault, calmly say, “I don’t know who all was in the room we are going to review this error completely and thoroughly; I will share all the information with you as soon as I can”; address organ donation or need for autopsy as circumstances or law requires; tell them what you will do; offer them coffee, water, facial tissues, lodging, transportation, communication with family members or clergy, access to patient advocate or risk manager; if they want you to talk to their attorney, do not say “no,” but say, “I really don’t know if I can but let me check into it” After disclosing: immediately document what took place

Audiodigest Anesthesiology 2003

Swiss cheese model by James Reason published in 2000 (1). Depicted here is a more fully labelled black and white version published in 2001 (5). On the survey questionnaire, all labels and comments were hidden.

Vulnerable System Syndrome

(Quality in Health Care 2001;10(Supp II):ii21-25)

Patterns of error in 2594 trauma deaths (Ann Surg 2006;244:371)

JCAHO Patient Safety Event Taxonomy

(Int J Quality in Health Care 2005;17(2):95)

Types of Errors

(Type 1 errors are false positives and

type 2,false negatives. A

type 3 error is solving the wrong problem,and a

type 4 error is solving the right problem too late.)

Interruptions and Errors

review