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Presented at the3rd Middle East Patient Safety Conference           17 – 19 October 2010                              Pres...
About Tawam Tawam Hospital is a 477-bed tertiary care facility  located in Al Ain, Abu Dhabi, and one of the largest  hos...
Subtracting Insult from Injury Statement by: JONATHAN R. COHEN                                  (Assistant Professor, Uni...
Ice- Breaker Is there a possibility that the boy’s death could have  been due to a medical error?
Medical Error- Definition Failure of a planned action to be completed as intended or use of a wrong plan to achieve an ai...
Disclosure of medical error-Definition “Communication of a health care provider and a  patient, family members, or the pa...
Problem Australia: 18,000 annual deaths from Medical errors,    1995.   U.S: 44- 98,000 Deaths/year (IOM, 1998)   Unite...
This is what we see?
Medical mistakes cases referred - United Arab Emirates: Saturday, June 10 - 2006The UAE Ministry of Health has referred 35...
What happens after a medical error?
Physicians Response For a physician being involved in an error evokes  emotions such as shame, humiliation, fear, panic, ...
Physicians Response     The types of suffering are            Increased anxiety about the future possibility of errors, ...
Patients Reactions A common human response to something going  wrong is to ask: ‘What happened?’ Patients interpret deni...
Medical error: the second victim..     The term second victim was initially coined by Wu in his      description of the i...
Is disclosure the right thing to do?What professional societies say? American Medical Association has identified it  as e...
Is disclosure the right thing to do?What professional societies say? Contd…. American Society for Healthcare Risk  Manage...
Disclosure helps in not getting sued.What research says? Full disclosure is found to have a moderating effect  on liabili...
Nondisclosure/ Liability Cycle
What is the relationship between disclosureand litigation? Failure to disclose leads patients filing claims. Disclosure ...
Significant Barrier       A common perception among physicians is that good        doctors don’t make mistakes.       Ph...
Significant Barrier- Communication Communication skills are not routinely taught to  physicians or any healthcare provide...
Actions Directed at answering the initial patient worries of  ‘what happened?’, ‘what is next?’, ‘is this fixable?’ Prov...
How to Say Im Sorry  Detailed account of the situation  Acknowledgement of the hurt or damage done  Taking responsibili...
Medical Errors and the Full Disclosure/     Early Offer Movement-Doug Wojcieszak       Three guiding principles designed ...
Tim McDonald-     But ‘I’m sorry’ alone doesn’t work.”        Disclose and apologize doesn’t mean the hospitals or       ...
University of Illinois health system     in Chicago        Patient-family members sit alongside staff on a board         ...
Other Examples    The University of Michigans program of full       disclosure and compensation for medical errors       ...
Overcoming barriers to error disclosure Culture of blame – shift focus to constructive approach      - What lessons can w...
Overcoming barriers to error disclosure Institution support      - Establish disclosure support system         Provide d...
Overcoming barriers to error disclosure Institution support    Require medical staff to engage in error disclosure     a...
Overcoming barriers to error disclosure Institution support    Provide language interpreter    Provide patient-physicia...
Overcoming barriers to error disclosure Role of care providers    Participation in disclosure education and skill traini...
Overcoming barriers to error disclosure Role of care providers   Prepare before meeting with patient and family (Role   ...
Old proverb till holds good “To err is human, to forgive divine” - Alexander  Pope (1688-1744) “Justifying a fault doubl...
How to implement open disclosure Establishing a “ Culture of Safety” Leadership engagement-”Achieve “buy in” from top,  ...
What we have done in Tawam Created the Patient Safety dept Senior Executive Partnership Leadership were trained on Pati...
References: Courtney J Wusthoff (2001). Medical mistakes and  disclosure: the role of the medical student. JAMA.  286:108...
References:   Improving patient safety in hospitals (2002) University of Michigan    Health System Patient Safety Toolkit...
References: Department of Veterans Affairs (Veterans Health Administration)  Disclosure of adverse events to patients: VH...
References: The Joint Commission report. “What Did the Doctor Say?:” Improving  Health Literacy to Protect Patient Safety...
References:   Hickson, G. B., Clayton, E. W., Githens, P. B., et al.    Factors that prompted families to file medical   ...
References: Vincent, C., Young, M., and Philips, A. Why do people sue    doctors? A study of patients and relatives takin...
References:   Massachusetts Coalition for the Prevention of Medical Errors    (2006), When things go wrong: Responding to...
Apologizing Effectively to Patientsand Families IHI Open School Video
RequestOpen disclosure of medical errors is a sensitive topicIt is quite challengingLets make a beginningLets start ta...
Patient Safety Top Priority“Cultural change is both evolutionary and revolutionary”                 Thank you
Subtracting insult from injury  disclosure of medical errors
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Subtracting insult from injury disclosure of medical errors

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“Subtracting insult from injury- Disclosure of medical errors”

Patients are often in vulnerable physical or psychological states, even with routine procedures. Therefore, when harm from an unexpected event occurs, especially from someone they trust, reactions can be severe and traumatic. A common human response to something going wrong is to ask: ‘What happened?’

A health care provider goes through the same issues after an error and equally powerful emotions are felt, such as shame, humiliation, fear, panic, guilt, anger and self-doubt. In response to this stress, physicians employ several coping mechanisms, including denial and distancing. “Physicians felt upset and guilty about harming the patient, disappointed about failing to practice medicine to their own high standards, fearful about possible lawsuit, and anxious about the error’s repercussions regarding their reputation” (Gallagher, Waterman & Ebers, 2003, p. 1005). This is compounded by fear of litigation, which causes physicians to feel guarded in their dealings with patients following an error.
The healthcare professionals who are at the so-called “sharp end” of medical error are called the “Second Victim.”

A common perception among physicians is that good doctors don’t make mistakes. Because of this, physicians learn to keep mistakes to themselves rather than risk the judgment of their peers. In fact, the pressure to be perfect is so great that doctors admit they would lie to colleagues or patients to cover up a mistake. Out of concern for liability exposure, some doctors have given up their practices, limited the kinds of procedures they perform, or restricted the types of patients they see.

Some patients resort to threatening with lawsuits to get things straightened up. Growing evidence indicates apologies reduce litigation and offer great, though unquantifiable, emotional benefits for patients, families, and health care providers.

A trusting relationship between provider and patient is the bedrock of medical care. Following an adverse medical event, patient and provider relationships face their greatest test. The key to success is open patient–provider communication and a true sense of caring.
Helping to maintain a patient–provider relationship is an apology, and then personal, repeated attention to the needs of the patients and families. Patients need action taken quickly and confidently by providers. Quick action provides a sense of reassurance in the confusion. This action must be directed at answering the initial patient worries of ‘what happened?’, ‘what is next?’, ‘is this fixable?’ Provider support of the patient must follow quickly and continue as the process unfolds.


Learning Objectives:
Understanding the principles of Disclosure
Understanding provider and patient expectations of error disclosure
Understanding risks & benefits of medical error disclosure

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Transcript of "Subtracting insult from injury disclosure of medical errors"

  1. 1. Presented at the3rd Middle East Patient Safety Conference 17 – 19 October 2010 Presented by Krishnan Sankaranarayanan MBA Senior Officer Patient Safety Department of Performance Innovation Tawam Hospital, Al Ain, UAE. Disclosure: The presenter has nothing to disclose, nor has any commercial interest with any of those informations displayed in this presentation.
  2. 2. About Tawam Tawam Hospital is a 477-bed tertiary care facility located in Al Ain, Abu Dhabi, and one of the largest hospitals in the United Arab Emirates. In 2006 Tawam Hospital entered a ten year affiliation with Johns Hopkins Medicine.
  3. 3. Subtracting Insult from Injury Statement by: JONATHAN R. COHEN (Assistant Professor, University of Florida) Apologies benefit the victim and the wrongdoer:  The Victim feels acknowledged  The wrongdoer feels forgivenCohen JR. Advising clients to apologize. Southern California Law Review 1999;72:1009–69.
  4. 4. Ice- Breaker Is there a possibility that the boy’s death could have been due to a medical error?
  5. 5. Medical Error- Definition Failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim. (Kohn, et al 2000) Errors can include problems in practice, products, procedures, and systems.
  6. 6. Disclosure of medical error-Definition “Communication of a health care provider and a patient, family members, or the patient’s proxy that acknowledges the occurrence of an error, discusses what happened, and describes the link between the error and outcomes in a manner that is meaningful to the patient.”Fein et al.: Journal of General Internal Medicine, March, 2007: 755-761 Disclosure of medical error is not a single conversation; rather, it needs to occur over time, in a series of conversations. Straumanis, 2007
  7. 7. Problem Australia: 18,000 annual deaths from Medical errors, 1995. U.S: 44- 98,000 Deaths/year (IOM, 1998) United Kingdom: 850,000 incidents/year, 2000. Canada: Adverse events in 7% of Admissions 9-24,000 deaths/year. 2004. Middle East: There are lack of statistical evidence in this region to showcase patient deaths happening due to medical error.
  8. 8. This is what we see?
  9. 9. Medical mistakes cases referred - United Arab Emirates: Saturday, June 10 - 2006The UAE Ministry of Health has referred 35 complaints from patients alleging mistakesin their treatment to the Abu Dhabi National Insurance Company, reported Gulf News.The complaints have been reported by patients and investigated over the past sixmonths. The cases have been passed to the insurance company in order to handle anycompensation if it is awarded by the courts
  10. 10. What happens after a medical error?
  11. 11. Physicians Response For a physician being involved in an error evokes emotions such as shame, humiliation, fear, panic, guilt, anger and self-doubt. (Wu, 1991 & Hilfiker, 1984) Physicians employ several coping mechanisms, including denial and distancing. (Mizrahi, 1984 & Wu, 1993) Causes physicians to feel guarded in their dealings with patients following an error. (Robin, 1998)
  12. 12. Physicians Response  The types of suffering are  Increased anxiety about the future possibility of errors,  Loss of confidence in the work they do,  Some face difficulty sleeping,  Concern about their reputation as a physician and  Reduction in their sense of job satisfaction.  Excellent clinicians may leave the profession prematurely when involved in a preventable error.Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. JtComm J Qual Patient Saf 2007;33:467–76.Rossheim J. To err is human—even for medical workers. Healthcare monster. http://healthcare.monster.ca/8099_en-CA_pf.asp (accessed 21Jan 2009).
  13. 13. Patients Reactions A common human response to something going wrong is to ask: ‘What happened?’ Patients interpret denial, distancing and withdrawal as rejection, and they feel angry and betrayed. This anger and betrayal, coupled with a sense that the physician is not being honest, that prompts patients to file claims. (Hickson, 1992, Witman, 1996 & Hingorani 1999)
  14. 14. Medical error: the second victim..  The term second victim was initially coined by Wu in his description of the impact of errors on professionals. The doctor who makes the mistake needs help too.  In the aftermath of a mistake, its important the doctor seek support to deal with the consequences.Albert W Wu associate professorSchool of Hygiene and Public Health and School of Medicine, JohnsHopkins University, Baltimore, MDWu AW (2000). "Medical error: the second victim. The doctor who makes the mistake needs help too". BMJ 320 (7237): 726–7.
  15. 15. Is disclosure the right thing to do?What professional societies say? American Medical Association has identified it as ethical obligation to disclose. American college of Physicians in its ethical manual state that physicians should disclose to patients information about procedural or judgment errors. American Nurses Association and the American College of Healthcare Executives have code of ethics that require professionals to respect human dignity and conduct professional activities with honesty.
  16. 16. Is disclosure the right thing to do?What professional societies say? Contd…. American Society for Healthcare Risk Management calls for practicing the profession with honesty and integrity while avoiding unjust harm to others. National Patient Safety Foundation calls for providers to disclose medical injury to patients.
  17. 17. Disclosure helps in not getting sued.What research says? Full disclosure is found to have a moderating effect on liability and expense payments. Research shows:- (Survey)  24% of patients filed claims because they believed that the physicians were not totally honest or covering up important information. (Hickson, 1992)  39% of patients would not have filed claims if they had received explanation and an apology. (Vincent 1994)  Patients were more likely to sue if they learned of a physician’s error from some other source. (Witman, 1996)
  18. 18. Nondisclosure/ Liability Cycle
  19. 19. What is the relationship between disclosureand litigation? Failure to disclose leads patients filing claims. Disclosure does not lead to litigation and may in fact curb liability and expense payments. Disclosure helps early and amicable settlement.
  20. 20. Significant Barrier  A common perception among physicians is that good doctors don’t make mistakes.  Physicians learn to keep mistakes to themselves rather than risk the judgment of their peers.  The pressure to be perfect is so great that doctors admit they would lie to colleagues or patients to cover up a mistake.  Out of concern for liability exposure, some doctors have given up their practices, limited the kinds of procedures they perform, or restricted the types of patients they seeGreen, M.J., Farber, N.J., and Ubel, P.A. Lying to each other. Archives of Internal Medicine, 2000;160:2317-23.Mizrahi, T. Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Social Science & Medicine,1984;19(2):135-46
  21. 21. Significant Barrier- Communication Communication skills are not routinely taught to physicians or any healthcare provider. In a study 50% of the Physicians said they had never received any formal training on handling medical mistakes. (Maithel, 1998) In another study physicians agreed disclosure was required, they questioned their ability to do so. (Sweet, 1997 & Gray, 1990)
  22. 22. Actions Directed at answering the initial patient worries of ‘what happened?’, ‘what is next?’, ‘is this fixable?’ Provider support of the patient must follow quickly and continue as the process unfolds. Disclosure also restore patients trust in the system.
  23. 23. How to Say Im Sorry  Detailed account of the situation  Acknowledgement of the hurt or damage done  Taking responsibility for the situation  Recognition of your role in the event  Statement of regret  Asking for forgiveness  A promise that it wont happen again  A form of restitution whenever possible
  24. 24. Medical Errors and the Full Disclosure/ Early Offer Movement-Doug Wojcieszak  Three guiding principles designed to encourage full disclosure for medical errors with fair, upfront and early compensation. 1. Compensate quickly and fairly when inappropriate medical care causes injury; 2. Defend medically appropriate care vigorously; 3. Reduce patient injuries (and therefore claims) by learning from mistakes.Quoted in http://www.sorryworks.net/files/CoalitionPowerpointpresenation.ppt #261,8, Goals of the Coalition
  25. 25. Tim McDonald- But ‘I’m sorry’ alone doesn’t work.”  Disclose and apologize doesn’t mean the hospitals or doctors say to a patient or family, “Something went wrong. We’re sorry. Here’s a check. Ciao.”  It means, or should mean, they say something like, “You had a bad outcome. We are sorry. We will try to help you while we investigate what happened. If it was our fault, we will take financial and moral responsibility. We will do our best to make sure it never happens again to anyone else.”Tim McDonald, a physician and lawyer who is chief safety and risk officer at the University of Illinois health system in Chicago
  26. 26. University of Illinois health system in Chicago  Patient-family members sit alongside staff on a board charged with overseeing plans to prevent errors  Dr. McDonald says that over the past four years, the number of lawsuits against the center is down 40% compared to the period between 1999 and 2004, even though the number of procedures increased 23%Tim McDonald, a physician and lawyer who is chief safety and risk officer at the University of Illinois health system in Chicago
  27. 27. Other Examples  The University of Michigans program of full disclosure and compensation for medical errors resulted in a decrease in new claims for compensation (including lawsuits), time to claim resolution and lower liability costsA study published Aug. 17 in the Annals of Internal Medicine.
  28. 28. Overcoming barriers to error disclosure Culture of blame – shift focus to constructive approach - What lessons can we learn? - Are there systems/design issues? - Are there communication issues? - Are there ethical concerns? - How can we improve performance?
  29. 29. Overcoming barriers to error disclosure Institution support - Establish disclosure support system  Provide disclosure education  Ensure disclosure coaching available at all times  Provide emotional support (healthcare workers, administration, patients and families)
  30. 30. Overcoming barriers to error disclosure Institution support  Require medical staff to engage in error disclosure activities  Integrate disclosure, patient safety and risk management activities  Use performance improvement tools to track and enhance disclosure
  31. 31. Overcoming barriers to error disclosure Institution support  Provide language interpreter  Provide patient-physician liaison  Provide system of rewarding error reporting  Provide continuing education on error disclosure  Provide systems changes to decrease error occurrence
  32. 32. Overcoming barriers to error disclosure Role of care providers  Participation in disclosure education and skill training  Follow guidelines for error reporting  Utilize resources for error disclosure  Actively lobby for laws  Participate in safety and quality improvement activities
  33. 33. Overcoming barriers to error disclosure Role of care providers  Prepare before meeting with patient and family (Role Play and practice)  Review and know current facts of event  Be ready for intense emotion  Have legal representation if patient has one  Use plain language  Do not rush conversation (Never say I know how difficult it is) - Straumanis, 2007
  34. 34. Old proverb till holds good “To err is human, to forgive divine” - Alexander Pope (1688-1744) “Justifying a fault doubles it” a French Proverb.
  35. 35. How to implement open disclosure Establishing a “ Culture of Safety” Leadership engagement-”Achieve “buy in” from top, bottom & sideways” Identify potential champions and possible stakeholders. Must create an accounting method for remedies. Community involvement and education. Identify and establish – “Micro system”- cultural is local. Simulation Training- create standardized patients. Celebrating safety- Encourages open reporting.
  36. 36. What we have done in Tawam Created the Patient Safety dept Senior Executive Partnership Leadership were trained on Patient Safety Rolled out the Johns Hopkins-”Comprehensive Unit- based Safety Program” (CUSP). Implemented “Patient Safety Net" online incident reporting system. Instituted the “Best Catch Award” Created a Patient Safety video (Arabic Version- http://www.youtube.com/watch?v=IkM-V0NIU5U )
  37. 37. References: Courtney J Wusthoff (2001). Medical mistakes and disclosure: the role of the medical student. JAMA. 286:1080–1081. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. (2003). Patients and doctors attitudes regarding the disclosure of medical errors. JAMA. 289:1001– 1007. Mazor KM, Simon SR, NGurwitz JH (2004). Communicating with Patients about Medical Errors - A Review of the Literature. Arch Intern Med. 164:1690–1697. Gert B, Culver CM, Clouser DK (2006) Bioethics: A Systematic Approach. Oxford: Oxford University Press.
  38. 38. References: Improving patient safety in hospitals (2002) University of Michigan Health System Patient Safety Toolkit, http://www.med.umich.edu/patientsafetytoolkit/ accessed September 27, 2009. Perspective on disclosure of unanticipated outcome information (2001). American Society for Healthcare Risk Managemet (AHA) Whitepaper, www.ashrm.org/ashrm/education/development/monographs/Discl osure.2001.pdf accessed September 27, 2009. Gallagher TH, Content of medical error disclosures (2004), Virtual Mentor, vol 6 (3), http://virtualmentor.ama-assn.org/2004/03/pfor1- 0403.html accessed September 26, 2009. American Medical Association. Code of Medical Ethics of the American Medical Association: current opinions with annotations 2006-2007ed. Chicago: AMA, 2006.
  39. 39. References: Department of Veterans Affairs (Veterans Health Administration) Disclosure of adverse events to patients: VHA Directive 2008-002. January 18, 2008. American College of Obstetrician Gynecologists Committee Opinion Number 380, Disclosure and discussion of adverse events (2007), Obstetrics and Gynecology, 2007. Massachusetts Coalition for the Prevention of Medical Errors (2006), When things go wrong: Responding to adverse events A consensus statement of the Harvard Hospitals, http://www.macoalition.org accessed September 26, 2009. Boothman RC, Blackwell AC, Campbell DA, Commiskey E, Anderson S (2009). A better approach to medical malpractice claims? The University of Michigan experience, J Health & Life Sciences Law, vol 2(2), pp. 125-159
  40. 40. References: The Joint Commission report. “What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety. (2007). Retrieved Sept. 27, 2009, from the Joint Commission Website: http://www.jointcommission.org/nr/rdonlyres/d5248b2e- e7e6-4121-8874-99c7b4888301/0/improving_health_literacy.pdf Gabriel, Barbara A. (Nov. 2007). The Law: Apology Accepted?: More physicians are learning to say “I’m sorry” when medical mistakes happen. Retrieved Sept. 27, 2009, from Physicians Practice Website: http://www.physicianspractice.com/index/fuseaction/articles .details/articleID/1084/page/1.htm AMA Code of Medical Ethics: Opinion 8.121 - Ethical Responsibility to Study and Prevent Error and Harm (Dec. 2003). Retrieved Sept. 27, 2009, from the American Medical Association Website: http://www.ama-assn.org/ama/pub/physician-resources/medical- ethics/code-medical-ethics/opinion8121.shtml
  41. 41. References: Hickson, G. B., Clayton, E. W., Githens, P. B., et al. Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA, 1992;267:1359-63. Witman, A. B., Park, D. M., and Hardin, s. B. How do patients want physicians to handel mistakes? A survey of internal medicince patients in an academic setting, Archives of Internal Medicine, 1996;156(22):2565-69. Karaman, S.S., and Hamm, G. Risk management: honesty may be the best policy. Annals of Internal Medicine, 1999:131(12):963-67. Hickson, 1992.
  42. 42. References: Vincent, C., Young, M., and Philips, A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet, 1994;343:1609-13. Witman, 1996 Stafford v. Shultz, 42 Cal.2d. Kreugar v. St Joseph’s Hospital, 305 N.W.2d 18. http://www.perfectapology.com/index.html
  43. 43. References: Massachusetts Coalition for the Prevention of Medical Errors (2006), When things go wrong: Responding to adverse events A consensus statement of the Harvard Hospitals, http://www.macoalition.org accessed September 26, 2009. Perspective on disclosure of unanticipated outcome information (2001). American Society for Healthcare Risk Managemet (AHA) Whitepaper, www.ashrm.org/ashrm/education/development/monographs/Discl osure.2001.pdf accessed September 27, 2009. Improving patient safety in hospitals (2002) University of Michigan Health System Patient Safety Toolkit, http://www.med.umich.edu/patientsafetytoolkit/ accessed September 27, 2009. Boothman RC, Blackwell AC, Campbell DA, Commiskey E, Anderson S (2009). A better approach to medical malpractice claims? The University of Michigan experience, J Health & Life Sciences Law, vol 2(2), pp. 125-159.
  44. 44. Apologizing Effectively to Patientsand Families IHI Open School Video
  45. 45. RequestOpen disclosure of medical errors is a sensitive topicIt is quite challengingLets make a beginningLets start talking about it
  46. 46. Patient Safety Top Priority“Cultural change is both evolutionary and revolutionary” Thank you
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