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 for Accreditation of Healthcare Organizations 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. Most 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.

Doctors in Touch is a proprietary organization which produces materials to aid doctors in strengthening physician relationships with patients. It has published materials on communicating with patients about medical errors (see book listing below by Michael Woods). More information can be found at www.doctorsintouch.com.

A Curbside Consultation: Disclosing a Medical Error. American Family Physician:Vol. 60/No. 3 (September 1, 1999) at http://www.aafp.org/afp/990901ap/curbside.html

Apology and disclosure process and guidelines. Oak Park, IL: Doctors in Touch, 2004.

Banja JD. Persisting problems in disclosing medical error. Harvard Health Policy Review 2004;5:14-20. Available at http://www.hcs.harvard.edu/~hhpr/publications/previous/04s.

Berlinger N, Wu AW. Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error. Journal of Medical Ethics 2005:31:106-108. Abstract at http://jme.bmjjournals.com/cgi/content/abstract/31/2/106.

Cantor MD, Barach P, Derse A, et al. Disclosing adverse events to patients. Joint Commission Journal on Quality and Patient Safety 2005;31:5-12.

Communicating outcomes to patients. St. Paul, MN: Minnesota Hospital Association, 2002. Available at http://www.aha.org/aha/ptcommunication/content/mn_communicating_outcomes_030714.pdf.

Disclosure: what works now and what can work even better. Chicago, IL: American Society for Healthcare Risk Management, 2004. Available at http://www.hospitalconnect.com/ashrm/resources/files/Disclosure.Part3.0204.pdf.

Discussing unanticipated outcomes and disclosing medical errors. Atlanta, GA: Emory University Center for Ethics, 2004. Available at http://ethics.emory.edu/media/error.htm.

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.

Gallagher TH, Waterman AD, Ebers AG, et al. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA 2003;289:1001-1007. Abstract at http://jama.ama-assn.org/cgi/content/abstract/289/8/1001.

Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Annals of Internal Medicine 1999;131:963-967. Available at http://www.annals.org/cgi/reprint/131/12/963.pdf.

Lamb R. Open disclosure: the only approach to medical error. Quality and Safety in Health Care 2004;13:3-5. Available at http://qhc.bmjjournals.com/cgi/content/full/13/1/3.

Lamb RM, Studdert DM, Bohmer RMJ, et al. Hospital disclosure practices: results of a national survey. Health Affairs 2003;22:73-83. Abstract at http://content.healthaffairs.org/cgi/content/abstract/22/2/73; letters and authors' reply at http://content.healthaffairs.org/cgi/reprint/22/3/249.

Let's talk: disclosure after an adverse event. National Patient Safety Foundation, 2002. More at http://npsf.org/rc/pvc/letstalkvideo.php.

Liebman CB, Hyman CS. A mediation skills model to manage disclosure of errors and adverse events to patients. Health Affairs 2004;23:22-32. Abstract at http://content.healthaffairs.org/cgi/content/abstract/23/4/22.

Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors: a review of the literature. Archives of Internal Medicine 2004;164:1690-1697. Abstract at http://archinte.ama-assn.org/cgi/content/abstract/164/15/1690.

NPSF bibliography - disclosure issues. National Patient Safety Foundation, August 2004. Available at http://www.npsf.org/rc/pubs/ca/CA/CA_Aug1_04.html.

Removing insult from injury: disclosing adverse events. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health, 2004. Available at http://www.jhsph.edu/Dept/HPM/Research/Wu_video.html.

Medical Errors and Medical Narcissism by John D. Banja, published in December 2004
ISBN: 0763783617
Publisher: Jones & Bartlett Publishers, Inc.
SYNOPSIS
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 by Dr. Aaron Lazare
Published by Oxford University Press (September 2004) Available at www.oup.com/us/?view=usa
"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 by Dr. Michael Woods
Available at www.doctorsintouch.com

Healing the Wounds-A Physician Looks at His Work by David Hilfiker, 1998

Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande, For a brief description see the Amazon.com editorial review at: www.amazon.com

(March Board 2006)