Urging doctors to take responsibility for their mistakes

In 2007, I published a story in my local paper in which I confessed to having made a medical error years earlier. I’d mistakenly prescribed an antibiotic for a patient whose chart indicated an allergy to the drug.

Thankfully, the story had a happy ending. My patient recovered and took no legal action after I explained to her what had happened. I ended my article vowing to take greater care to prevent errors and urging doctors to take responsibility for their mistakes, even when a patient hasn’t been harmed.

The response among many of my colleagues was: Why? If a patient makes a full recovery, why should doctors admit to a mistake that might have otherwise gone unnoticed? Our intentions as doctors are good, and confessing our errors would only create unnecessary personal humiliation and undermine our authority. Moreover, what if the patient looks at an admission of error as a winning ticket in the malpractice lottery?

Like me, many of my colleagues were never taught how to disclose errors in medical school. Errors were considered incidental lapses and used as teaching points among residents; we were not to discuss them with patients unless absolutely necessary. When I joined a private practice 18 years ago, our hospital and malpractice lawyers told us never to admit guilt. Risk managers were clear that we were to contact them in the event of an error. If patients’ families had questions, we were to be vague with our responses, essentially brushing them off.

Gradually, such attitudes and practices have been changing. First, policymakers, doctors and other providers have realized that medical errors are often systemic problems rather than incidental lapses. And error disclosures, once considered an ethical obligation to be treated as a problem only if a patient sued, are now being written into hospital policy.

In 2001, the organization that accredits hospitals developed national standards for a more coordinated approach to reporting errors and protecting patients, and from 2002 to 2005 the proportion of hospitals with disclosure policies doubled to 70 percent, according to a 2007 New England Journal of Medicine article. (A 2002 NEJM study had found that only one in three preventable medical errors was being disclosed to patients.) The national standards require that patients be informed of all outcomes of care, including “unanticipated outcomes.”

While this policy shift alerted physicians like me to a change in perspective, it did little to change our behavior. Many doctors were trained in an autocratic and sometimes patronizing culture, and there were few incentives or penalties to push change.

In 2006, a working group representing Harvard-affiliated hospitals established that a disclosure policy must include three elements: The provider must take responsibility, apologize and discuss preventive measures with the patient or the family.

For example, if I inadvertently gave penicillin to a patient with a known allergy and she had a reaction, I would tell the patient I had made an error, apologize for my mistake and talk about how I will make an effort to prevent making such an error in the future.

Reaching this stage of disclosure has been difficult. But virtually every medical school is addressing it. The University of Washington has developed an especially innovative approach, which recognizes that most errors in health care result from the actions of teams of providers rather than from the actions of any individual. So medical, nursing, pharmacy and other students of the health professions go through lectures and practice disclosure skills with actors posing as patients.

“Learning to disclose errors as a team is a terrific way to learn how to work together effectively,” said Sarah Shannon, an associate professor of biobehavioral nursing and health systems in the university’s nursing school. “Errors raise the ante for the health-care team by bringing up reactions of guilt and blame, grief and anger among the team members, as well as between the team and the patient and family. Acquiring the skills to approach error disclosure effectively can carry over to other team communication. We make errors as a team; we need to disclosure errors as a team.”

Telling a patient about a mistake can enhance the doctor-patient relationship. A 2006 study in the Journal of General Internal Medicine found that “full disclosure after a medical error reduces the likelihood that patients will change physicians, improves patient satisfaction, increases trust in the physician, and results in a more positive emotional response.”

One surgical colleague’s story, a story that I have recounted in the past, is illustrative: During a cardiac bypass operation, the surgeon left a sponge in a patient’s chest. The surgeon promptly approached the family, apologized, took responsibility, researched why the error was made, offered to have another surgeon take over the care and waived all additional medical charges. The family chose to have the apologetic surgeon remove the sponge.

After patients learn of a medical error, they are often reluctant to formally report the event because they want to put it behind them and focus on their own health, according to a 2012 study in the Journal of Clinical Oncology of people who believed that they had been the victims of medical error. But almost all of these patients said that they would make changes in their behavior, such as asking more questions about their care.

Nationally, as disclosure policies become institutionalized and doctor groups encourage members to talk to their patients when errors occur, some models have shown success, at least in reducing medical malpractice suits.

The University of Michigan Health System implemented a disclosure program in 2001 and compared liability claims for six years before and after its implementation: Annual litigation expenses dropped from $3 million to $1 million over that period, and the number of claims decreased by 50 percent.

Yet a study last year in Health Affairs found that error disclosure, resolution and compensation did not necessarily decrease the likelihood that a patient would pursue legal advice.

Some states have taken legislative action on disclosure of medical errors. For example, Pennsylvania in 2002 adopted a law requiring hospitals to notify patients in writing within seven days after a serious event occurs; this communication cannot be used as evidence of liability in court. Nearly 34 states and the District have adopted “apology laws” that protect parts of a doctor’s conversation as evidence of liability in a lawsuit.

But Tom Gallagher, an internist and a researcher on disclosure at the University of Washington, points out that most of these laws have “major shortcomings,” in that they do not adequately protect the physician from malpractice suits, as the Pennsylvania law does. This is a prime concern for doctors fearing to admit error.

The federal Agency for Healthcare Research and Quality is engaged in demonstration projects to figure out the best approach for error disclosure and malpractice reduction in nonacademic, private practice settings. According to Gallagher, early findings suggest that key stakeholders such as doctors, hospitals, trial lawyers and malpractice insurers — parties that are often adversaries — were willing with some incentives to collaborate to provide patients who have been injured with rapid information.

Yet medical errors still happen. In 2010, the Office of Inspector General of the Department of Health and Human Services reported that one in seven Medicare inpatients experience an adverse event during their hospital stay. Many of these incidents are incorrect medication dosing or hospital-acquired infection; a rare few are wrong-site surgeries or drug overdoses. And an estimated 44 percent of these are preventable.

Policies to help prevent medical errors and getting doctors to own up to them can go only so far. In the end, it is up to each doctor — and his or her conscience.

In the years since that first difficult bedside admission, I have done my best to avoid making medical errors, but I still make them. I still find it very hard every time I meet with a patient and family members to acknowledge that I made a mistake.

Recently, a patient who had an organ transplant a decade ago came to me with a vague illness. I ordered a panel of tests and sent him home. Two weeks later, he was admitted to the hospital with a terrible pneumonia and fever; a test for the viral infection had come back positive a week earlier, but I had failed to check back and the lab had not alerted me of the positive result.

I went to the patient’s bedside and apologized, promising to try to fix the problem. “That’s okay, doc. I am so grateful to all of you for keeping me alive for so many years,” he said, with oxygen tubes helping him breathe. After a two-week stay in the intensive care unit, he went home. And I moved on to my next patient, chastened but hopeful that I’d do better the next time.

Manoj Jain is an infectious disease physician and contributor to the Washington Post and The Commercial Appeal.  He can be reached at his self-titled site, Dr. Manoj Jain.

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