Now What? How to Disclose a Medical Error Thursday, September 14, 2006 12:00 – 1:00 p.m. EDT

1. Now What? How to Disclose a Medical ErrorThursday, September 14, 200612:00 – 1:00 p.m. EDT

2. Featured Speaker: Anne Matlow, MD, FRCPC Medical Director, Patient Safety Hospital for Sick Children Toronto, Canada

3. Moderator: Marlene R. Miller, MD, MSc, FAAP Director of Quality and Safety Initiatives Johns Hopkins Children’s Center Baltimore, Maryland

4. A story…….. Matt is a 7 year old boy with diabetes Admitted to hospital ward after surgery for appendicitis Elevated glucose Insulin ordered Nurse misreads order: 10 fold error Matt becomes hypoglycemic, seizes, aspirates and ends up in ICU

5. OBJECTIVES • Define the term, “disclosure,” and give at least one example of who should disclose a medical error and when disclosure should be performed. • Identify at least one example of ideal disclosure vs. non-ideal disclosure. • Apply two or more strategies to handle disclosure effectively in an ambulatory setting.

6. FRAMING THE ISSUE When things go wrong: responding to adverse events. Harvard Hospitals. March 2006. www.ihi.org Error: the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim Serious Error: has potential to cause permanent injury or transient but potentially life threatening harm Minor Error: does not cause harm or have the potential to do so Near Miss: could have caused harm but did not reach patient; intercepted

7. FRAMING THE ISSUE When things go wrong: responding to adverse events. Harvard Hospitals. March 2006. www.ihi.org Adverse event: aninjury caused by medical management rather than the patient’s underlying disease; = harm, injury, complication. Preventable adverse event: injury that results from an error or systems failure

8. FRAMING THE ISSUE When things go wrong: responding to adverse events. Harvard Hospitals. March 2006. www.ihi.org DISCLOSURE: Providing information to a patient and /or family about an adverse event or serious error = COMMUNICATION

9. WHAT IS THE RIGHT THING TO DO? MD Guilty Embarrassed Afraid MOM Worried upset MATT ?

10. The Essentials of Disclosure Why disclose? What types of events should be disclosed? What should be said? Who should disclose? To whom ? When and where should the disclosure take place? And how should it be done?

11. Why disclose? Legal Obligation Ethical imperative • Right thing to do • Respect of patient autonomy: AMA, CMA: rights of patients to receive all information necessary to make informed and educated decisions about their care Preserve Patient -physician trust

12. Why else? Policy Healing / closure for care giver • “Apologizing might, in fact, be a useful approach to resolving both physician and patient distress after an error.” Improve safety • “The need to tell patients about error’s cause and prevention could create stronger links between physicians and safety programs, reducing future errors.” Source: Gallagher, JAMA, Feb 2003

13. But………………….. Will I be sued???

14. Empirical Studies •  50% of lawsuits are launched due to suspicion of cover-up or desire for revenge (Hickson JAMA 1992;267:1359) • Almost all lawsuits involve a breakdown of the physician / patient relationship, less than 20% involve negligence (Green AIM 1988; 109:234)

15. Extreme Honesty May Be the Best PolicyLexington VAKraman & Hamm, AIM 1999; 131:963 86 % tile 22 % tile • Proactive full disclosure to patients who have been injured

16. Patients want to know more than what doctors want to tell Patients have a lower threshold for hearing the details

17. Parental Preferences for Error Disclosure, Reporting and Legal Action after medical error in the care of their children • ED, non acute illness, 500 participants • 4 scenarios, 5 scale Likert response • 99% wanted disclosure • one third of cases less likely to seek legal counsel with disclosure Hobgood Peds 2005;116:1276

18. What Patients Want When Things Go Wrong • an explicit statement that an error occurred, • to be told what the error was, • to be told why the error occurred, • to know what will be done to prevent recurrences, and • an apology Gallagher Arch Int Med 2005; 165: 1819 .

19. How would this go over? Scene takes place at the elevator…. • Oh hi, Mrs Jones. Too bad about Matt, huh? Diabetes is a bad disease and sometimes kids end up in intensive care!! Or • That stupid nurse! She can’t even read! What do they teach them in nursing school these days anyway?

20. About Disclosing… Remember: disclosure is a process, not a “one off” More information may emerge over time Take care of the patient now and later

21. What…….. • Acknowledge that the event occurred • Give the facts, in order, simply • Take responsibility and apologize • Commit to finding out why

22. …….what…….. • Explain what impact the event will have on the patient now and in the future • Describe steps being taken to mitigate the effects of the injury • Describe steps being taken to prevent a recurrence

23. When… • As soon as it is recognized that and the patient is physically and emotionally capable • Ideally within 24 hours after the event is recognized • Make sure the proper people are present • Ongoing communication may be required as more information is available • Follow up may be required

24. Hindsight Bias Richard Cook

25. Who Should Disclose? • Health care worker with whom the patient has a trusting relationship • Almost always the responsible physician • Others may be present: eg: nurse, pharmacist, trainee… not too many! • Primary nurse a good idea

26. To whom? • Parent or substitute decision maker • Patient if capable

27. Where… • In a quiet and private area • Have water and tissues

28. How……. • Sit down (not on the patient’s bed) • Eye level • Low, slow voice • Be aware of your body language • Don’t rush, be patient • Be compassionate, remorseful • Make sure they’ve understand • Do they need anything? • Invite further questions now and later

29. Basic steps for medical dialogue: • Prepare • Initiate conversation • Listen actively • Acknowledge what you have heard • Respond When things go wrong: responding to adverse events. Appendix D. Training for Communication. Harvard Hospitals. March 2006.

30. continued……………. • Prepare: facts, people, setting • Initiate conversation: assess readiness and comprehension • Present facts simply: what we know, what comes next • Apologize • Acknowledge and respond • Summarize • Document: describe the event and the discussion Adapted from: When things go wrong: responding to adverse events. Appendix D. Training for Communication. Harvard Hospitals. March 2006.

31. How about this? • Mrs Jones, you’ve had a long day, but I need to discuss something with you. • Matt’s seizure was caused by hypoglycemia. When he seized he aspirated which is why he is in the ICU. • It looks like he was given too much insulin. We are trying to understand how that happened. When I have more information I will share it with you. I’m so sorry this has happened. Do you have any questions?

32. ………………………. • I understand you are angry. • He is on antibiotics and it is likely he will recover from this pneumonia completely. • Let’s meet again tomorrow and I’ll update you. In the meantime, here is my home phone # in case you think of some questions for later. • Can I get you something before I leave?

33. in the ambulatory setting……….. Why should it be any different?

34. Another story…….. Ashley is an 8 year old girl with epilepsy Rx phenytoin and carbamazepine First office visit since hospitalization for seizures Review of office chart: subtherapeutic drug levels one week prior to admission to hospital Report filed before reviewed

35. The Essentials of Disclosure Why disclose? What types of events should be disclosed? What should be said? Who should disclose? To whom ? When and where should the disclosure take place? And how should it be done?

36. The Essentials of Disclosure Why disclose? √ What types of events should be disclosed? √ What should be said? √ Who should disclose? √ To whom ? Make sure the right person there When and where should the disclosure take place? May need extra time….. And how should it be done? √

37. OBJECTIVES • Define the term, “disclosure,” and give at least one example of who should disclose a medical error and when disclosure should be performed. • Identify at least one example of ideal disclosure vs. non-ideal disclosure. • Apply two or more strategies to handle disclosure effectively in an ambulatory setting.

38. In closing………………. All expression of truth does at length take this deep ethical form. Henry David Thoreau