Clinical Outcomes, Disclosing Unanticipated: A Resource Guide for Family Physicians (Position Paper)
In recent years the health care literature has been replete with studies documenting the all too frequent occurrence of clinical errors in hospital and office based medical practice. While it was common practice in the past to cover up such mistakes, today it is widely accepted that patients should be informed when errors occur. Standards promulgated by the Joint Commission make this an explicit requirement in the hospital setting. The question physicians must ask today is not whether to disclose a clinical mistake, but how to share the information. Many physicians are not familiar with the results of coordinated efforts by some health care organizations to institutionalize the disclosure of medical mistakes. By and large, these efforts have been quite positive in helping patients come to grips with the clinical consequences of a clinical error, aiding physicians who may be plagued by guilt following the occurrence of a clinical ‘mishap’, and in ameliorating liability costs. While many doctors fear that such disclosures will result in ruinous lawsuits, a number of the studies listed below suggest otherwise. A number of organizations, such as Sorry Works! (described below) have been created to assist physicians to communicate effectively with patients under the emotionally laden circumstances of a clinical error.
The Bibliography and Resource List which follows is meant to provide the busy clinician a reference point for learning more about approaches to disclosing medical mistakes. The articles and resources below are best explored before an unfortunate circumstance makes the need compelling. However, they will also be useful for those reaching out for ‘just-in-time’ knowledge. This resource listing is meant to be a useful, but not an exhaustive, guide to the literature on this subject and there is little doubt that additional resources will constantly be appearing.
Sorry Works: The Sorry Works! Coalition is a nationwide organization of doctors, lawyers, insurers, and patient advocates dedicated to promoting full-disclosure and apologies for medical errors as a “middle ground solution” to the medical liability crisis. It has published white papers and protocols for addressing medical errors and it is a major sponsor of legislation at the state level. It has an informative web site at www.sorryworks.net(www.sorryworks.net).
Bismark MM, The power of apology, N Z Med J. 2009;122(1304):96-106. Abstract at http://www.journal.nzma.org/journal/122-1304/3813(journal.nzma.org.nz).
Cherry RA, Marcus L, Dorn B. Reporting adverse events to partients: a step-by-step approach, Physician Exec J. 2010;36(3):4-6, 8-9. net.acpe.org/MembersOnly/pejournal/2010/MayJune/Cherry.pdf(www.net.acpe.org).
Communicating outcomes to patients. St. Paul, MN: Minnesota Hospital Association, 2002. Available at http://www.aha.org/content/00-10/mn_communicating_outcomes_030714.pdf(www.aha.org).
Disclosure: what works now and what can work even better. Chicago, IL: American Society for Healthcare Risk Management, 2004. Available at
Discussing unanticipated outcomes and disclosing medical errors. Atlanta, GA: Emory University Center for Ethics, 2004. Available at http://ethics.emory.edu/news/archives/000345.html.
Fein SP, Hilborne LH, Spiritus EM, et al. The many faces of error disclosure: a common set of elements and a definition. J Gen Intern Med. 2007;22(6):755-761. www.springerlink.com/content/ag6615m8713342n3/fulltext.html(www.springerlink.com).
Frenkel DN, Liebman CB. Words that heal. Annals of Internal Medicine 2004;140:482-483. Available at http://www.annals.org/cgi/reprint/140/6/482.pdf(www.annals.org).
Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356(26):2713-1719. http://nejm.org/doi/pdf/10.56/NEJMra070568(www.nejm.org).
Lazare A. Apology in medical practice: an emerging clinical skill. JAMA, 2006;296(11):1401-1404. http://jama.ama-assn.org/content/296/11/1401.full(jama.ama-assn.org).
McDonald TB, Helmchen LA, Smith KM, et al. Responding to patient safety incidents: the "seven pillars." Qual Saf Health Care, 2010;19(6):e11. http://qualitysafety.bmj.com/content/19/6/1.31/full(qualitysafety.bmj.com).(archinte.ama-assn.org)
O'Connor E. Disclosure of patient safety incidents: a comprehensive review. International Journal for Quality in Health Care, 2010;22(5):371-379. http://intghc.oxfordjournals.org/content/22/5/371.full(intqhc.oxfordjournals.org).
Roberts RG, The art of apology: when and how to seek forgiveness. Fam Pract. Manag. 2007;14(7):44-49.http://www.aafp.org/fpm/2007/0700/p44.html.
Sorensen R, Iedema R., Piper D, Manias E, Williams A, Tuckett A. Disclosing clinical adverse events to patients: can practice inform policy? Health Expect. 2010;13(2):148-159. Abstract at onlinelibrary.wiley.com/doi/10.1111/j.1369-7625.2009.00569.x/abstract(onlinelibrary.wiley.com).
Weiss PM, Miranda F. Transparency, apology and disclosure of adverse outcomes. Obstet Gynecol Clin North Am. 2008;35(1):53-62, viii. Abstract at www.obgyn.theclinics.com/article/S0889-8545(07)00124-6/abstract(www.obgyn.theclinics.com).
White AA, Bell SK, Krause MJ, et al. How trainees would disclose medical errors: educational implications for training programs. Med Educ. 2011;45(4):372-380. Abstract at onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2010.03875.x/abstract(onlinelibrary.wiley.com).
Medical Errors and Medical Narcissism by Banja JD, Sudbury, MA: Jones and Bartlett Publishers; 2004
In a book "dedicated to all healthcare professionals who did the right thing, when the right thing was very, very difficult," clinical ethicist Banja (rehabilitation medicine, Emory U., Atlanta) presents the concept of "medical narcissism" to explain failure to disclose medical errors. The author offers insights into how professionals' self-esteem issues may subvert patient’s rights and advice on communicating about errors based on an emphatic model. He believes that ethical practice can be taught. Appendices discuss a neurologically-based model of rationalization, and the nature of pathological narcissism from a psychoanalytic perspective. Annotation ©2004 Book News, Inc., Portland, OR
On Apology. Lazare A. Oxford; New York: Oxford University Press; September 2004. Available at global.oup.com/academic/product/on-apology-9780195189117?q=on apology&lang=en&cc=us(global.oup.com)
"This jewel of a book reveals the many facets of the seemingly simple act of apology.... Drawing on a vast array of literary and real-life examples, from Agamemnon to George Patton to Arnold Schwarzenegger, from the current pope to the machinist who approached him after a lecture, Lazare lucidly dissects the process of apology.... Everybody on earth could benefit from this small but essential book."--Publishers Weekly (starred review)
Healing Words: The Power of Apology in Medicine. Woods MS. Oakbrook Terrace, IL: Joint Commission Resources; 2007. Available at store.jointcommissioninternational.org/healing-words-the-power-of-apology-in-medicine-second-edition(store.jointcommissioninternational.org).
Healing the Wounds-A Physician Looks at His Work. Hilfiker D. Omaha, NE: Creighton University Presss, 1998.
Complications: A Surgeon's Notes on an Imperfect Science. Gawande A. New York: Metropolitan Books; 2002. For a brief description see the Amazon.com editorial review at: www.amazon.com(www.amazon.com)
(March Board 2006) (2012 COD)