Should patients, families be told of mistakes?
A cross section of America’s health care risk managers believes patients and families should be told about medical mistakes, according to a national survey.
Conducted in April, the mail survey was reported for the first time in June at a national patient safety symposium, "Building Systems that Do No Harm: Advancing Patient Safety Through Partnership and Share Knowledge." More than 550 physicians, nurses, risk managers, administrators, and other health care professionals participated in the symposium, which was sponsored by VHA Inc.
In explaining why they believe patients and their families should be told about an error, responding risk managers most often chose the statement, "Health care providers have to disclose medical mistakes whether or not there was an injury, even if it will increase the risk of liability to the provider."
Risk managers responding to the survey said the top barriers to full disclosure were increased exposure to litigation and unwanted adverse publicity, says principal investigator Kathleen Ruroede, PhD, RN, of the Finch University of Health Sciences/The Chicago Medical School. She called for more education in the communication skills needed to communicate with patients and families about errors. The survey was funded by VHA Inc., a nationwide alliance of 1,900 hospitals.
Scenario and response
The survey presented risk managers with five hypothetical scenarios drawn from real cases: a surgical mishap, an unneeded mastectomy due to an erroneous lymph node diagnosis, two medication overdoses, and a child who wandered away from a pediatric unit through an unlocked door to a roof before being found unharmed. The surgical mishap scenario involved an inadvertent laceration of the pulmonary artery and the resulting death of a 70-year-old tuberculosis patient. A majority (61%) of survey respondents said the family should be told that the pulmonary artery was accidentally lacerated and caused a hemorrhage, resulting in the patient’s death.
In the breast cancer case, a large majority said the patient should be told of the diagnostic error, and 61% said the patient should be informed that the mastectomy was or may have been unnecessary. In the child-on-the-roof scenario, 66% of the responding risk managers said the parents should be told the child was found on the roof, upset and crying.
For one of the medication error episodes, involving administration of twice the ordered dose of the anti-convulsant Cerebyx, 57% of respondents indicated that the family should be told that the patient received an overdose that may have or probably contributed to his death.
The other medication overdose scenario, involving the administration of the anticoagulant heparin at 10 times the ordered dose, did not result in any apparent harm. Instead, the patient’s clotting times were tested immediately and every four hours for the next 24 hours. Sixty-four percent of the risk managers responding to the survey said the patient should be told that the additional testing was being done because too much heparin had been administered. The survey results, which were statistically significant, were based on 650 responses to questionnaires sent to 3,389 risk managers nationwide, representing a 20% response.
Also at the meeting, Gordon Sprenger, past president of the American Hospital Association, challenged the leadership of the health care industry to make patient safety a board-level priority and adopt full-disclosure policies in their organizations’ strategic plans. Sprenger, chief executive officer of Allina Health Systems, joined Julie Morath, chief operating officer of Children’s Hospitals and Clinics of the Twin Cities, in outlining a primary issue in creating a safer environment for patients: changing the culture of medicine from one of blame and secrecy to one of disclosure and learning.
"Patient safety should be on the personal agenda of every hospital CEO as it is the foundation for improving health care quality," he says. "To promote the culture change within our organizations that is necessary to reduce medical errors, we must shift the reporting emphasis to What happened?’ away from Who did what?’"
Morath adds that reducing medical errors "will take nothing less than making patient safety the first priority of hospitals’ strategic plans. To undertake such a vast cultural revolution means commitment to patient safety must be comprehensive, driven by leadership, with an emphasis on education as much as on changing infrastructure and systems."
How hospitals should proceed
Morath says a hospital’s plan to improve patient safety should include these elements:
• educational sessions and materials designed to promote an understanding of how systems can be changed to reduce the potential for harm;
• a full-disclosure policy to guide, support, and direct staff who interact with patients and families following medical accidents;
• a blameless reporting system designed to encourage staff to report "near misses"
• review and implementation of appropriate "best practices" that have been identified through the available research (for example, removing potassium chloride concentrates from units and 24-hour availability of pharmacists);
• regular reports to the CEO and board of directors.
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