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July 2007: VOLUME 4, NUMBER 11

Disclosure of Medical Errors

[EDITOR'S NOTE: For Respiratory Therapists interested in receiving CE credit for this program, please note that the map that illustrates the individual state requirements for CE credits has been updated. To view the map, please visit this page.]

In This Issue...

Since the publication of the 1999 report from the Institute of Medicine on errors in medical care, researchers and quality of care experts have worked diligently toward designing, implementing, and evaluating error reduction strategies. More recently, these efforts have included studies of both physician and patient attitudes toward the disclosure of medical errors.

In this issue, we review recent literature on parents’ perceptions of medical errors in the care of their children, pediatricians’ attitudes surrounding communication of errors, and the characteristics of complete error disclosure.
THIS ISSUE
IN THIS ISSUE
COMMENTARY from our Guest Author
REPORTING MEDICAL ERRORS:
AN OVERVIEW
PHYSICIAN ATTITUDES
PEDIATRICIAN ATTITUDES
PARENTAL PREFERENCES
CASE STUDY:
MEDICAL ERROR RESULTING IN DEATH
FACTORS PROMOTING MALPRACTICE CLAIMS
THE ELEMENTS OF ERROR DISCLOSURE
Course Directors

Edward E. Lawson, MD
Professor
Department of Pediatrics
Division of Neonatology
The Johns Hopkins University
School of Medicine

Christoph U. Lehmann, MD
Assistant Professor
Department of Pediatrics
Division of Neonatology
The Johns Hopkins University
School of Medicine

Lawrence M. Nogee, MD
Associate Professor
Department of Pediatrics
Division of Neonatology
The Johns Hopkins University
School of Medicine

Mary Terhaar, DNSc, RN
Assistant Professor
Undergraduate Instruction
JHU School of Nursing


Robert J. Kopotic, MSN, RRT, FAARC
Director of Clinical Programs
ConMed Corporation
GUEST AUTHORS OF THE MONTH
  Commentary:
Pamela Kimzey Donohue, ScD, PA-C
Director of Performance Improvement and Safety
Division of Neonatology
The Johns Hopkins University
School of Medicine
Reviews:
George Kim, MD
Research Associate
Neonatology and Health Sciences Informatics
The Johns Hopkins University
School of Medicine
Guest Faculty Disclosure

No faculty member has indicated that they have received financial support for consultation, research or evaluation or has a financial interest relevant to this literature review.


Unlabeled / Unapproved Uses

The authors have indicated that there will be no reference to unlabeled/unapproved uses of drugs or products in this presentation.

Course Directors' Disclosures
LEARNING OBJECTIVES
At the conclusion of this activity, participants should be able to:

Identify the key elements of complete error disclosure
Discuss the currently identified barriers to error disclosure
Explain the relationship between error disclosure and litigation
Program Information
CE Info
Accreditation
Credit Designations
Target Audience
Learning Objectives
Internet CME/CNE Policy
Faculty Disclosure
Disclaimer Statement

Length of Activity
1.0 hours Physicians
1 contact hour Nurses

Expiration Date
July 25, 2009

Next Issue
August 16, 2007
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COMMENTARY
As neither pediatric health care systems nor pediatric providers are infallible, errors happen in the medical care of children. Sharek and colleagues1 report 74 adverse events for every 100 patients admitted to a neonatal intensive care unit (NICU); studying 749 patients and 17,106 hospital days in 15 NICUs, they found the number of adverse events ranged from 0 to 11 per infant. It is not surprising, therefore, that 93% of the pediatricians surveyed by Garbutt et al2 reported involvement in a medical error.

Although the majority of pediatricians profess to support disclosing errors, less than half actually do so.2,3 A complex combination of personal and professional attitudes forms the basis for failure to disclose errors,3 with barriers including the fear of litigation, the inability to admit a mistake, and the fear of implicating other providers.4 Physician shame is also a powerful deterrent to error disclosure, and nowhere may this be truer than in pediatrics. According to Kaldjian et al,3 92% of physicians agree with the statement: "When I make a medical mistake, I am my own worst critic." Pediatricians not only have trouble forgiving themselves but also fear that others, including their patients’ parents, will be unforgiving.

However, little is known about parents’ perceptions of medical errors. In the only paper published to date targeting a pediatric population, Hobgood et al5 showed that parents want full disclosure of all medical errors, regardless of severity. The study also suggests that there may be racial differences in how parents perceive medical errors. Data from this study should encourage providers to disclose all errors to parents, even those they perceive to be minor, and thus avoid making assumptions about what parents want to know or should know about their child’s medical care.2

The need for transparency surrounding a medical error in pediatrics is highlighted by the case study presented by Keatings et al,6 in which communication concerning the circumstances leading to the death of an 11-year-old girl was both delayed and misleading. Poor communication between parents and physicians contributes to malpractice litigation.7Parents have been shown to be more satisfied with the quality of care and less likely to initiate legal action after an error if communication is honest and forthcoming.7,8 Parents also value physicians who listen and allow sufficient time for questions.

Professional organizations such as the Joint Commission and National Quality Forum stress the importance of properly communicating a medical error and endorse a 4-step process: 1) describe what happened as soon as it is known; 2) take responsibility; 3) apologize; and 4) review what steps are being taken to avoid a similar error in the future.4,9 Although these recommendations provide a straightforward framework, physicians have difficulty adhering to them in the high-stress context of error disclosure. Further, few physicians receive training in how to disclosure errors, and most have poor skills in doing so. Providers often disclose an error without "connecting the dots," ie, making it clear that a medical error caused the harm experienced by the patient.10 When asked, most physicians want coaching in how to do a better job. Using a simulation center could provide physicians and other healthcare professionals with experience in communicating errors before they are faced with the reality.

And directly to the point of this issue, research is urgently needed to help guide error disclosure in the NICU environment where exposure to high-risk medical care is prolonged.


References

1. Sharek PJ, Horbar JD, Mason W, et al. Adverse events in the Neonatal Intensive Care Unit: Development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics 2006;118;1332-1340.
2. Garbutt J, Brownstein DR, Klein EJ, et al. Reporting and disclosing medical errors: pediatricians' attitudes and behaviors. Arch Pediatr Adolesc Med. 2007;161:179-185.
3. Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE. Disclosing medical errors to patients: attitudes and practices of physicians and trainees. J Gen Intern Med. 2007;22:988-996.
4. Matlow A, Stevens P, Harrison C, Laxer RM. Disclosure of medical errors. Pediatr Clin North Am. 2006;53:1091-1104
5. Hobgood C, Tamayo-Sarver JH, Elms A, Weiner B. Parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children. Pediatrics. 2005;116:1276-1286.
6. Keatings M, Martin M, McCallum A, Lewis J. Medical errors: understanding the parent's perspective. Pediatr Clin North Am. 2006;53:1079-1089.
7. Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA. 1992;267:1359-1363.
8. Donn SM. Medical liability, risk management, and quality of health care. Semin Fetal Neonatal Med. 2005;10:3-9.
9. Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356:2713-2719.
10. 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;22:755-761.


REPORTING MEDICAL ERRORS: AN OVERVIEW
Matlow A, Stevens P, Harrison C, Laxer RM. Disclosure of medical errors. Pediatr Clin North Am. 2006;53:1091-1104.

(For non-journal subscribers, an additional fee may apply for full text articles.)
View journal abstract View full article
In their 1999 report "To Err is Human," the Institute of Medicine recommended that to improve the quality and safety of care, adverse events resulting from medical error should be disclosed to patients and their families. In this 2006 publication, Matlow et al examined medical error disclosure in several contexts, and provided summary consensus recommendations. Historically, the practice of advising physicians to "guard what is said to the patient" stems from a rise in malpractice cases in the early 20th century. More recently, however, this advice has been called into question in the face of ethical frameworks emphasizing physicians’ professional and fiduciary duties, respect for patients’ autonomy, and the inherent trust in a doctor-patient relationship. The authors report on medico-legal experience and mock trial studies, which suggest that proactive disclosure may lead to claims avoidance and more favorable outcomes (although they note that more research is needed in these areas). The researchers report that patients’ (and parents’) preference for full disclosure when a medical error has occurred is universal, with expectations of explicit statements that the error in fact occurred, what the error was, why it occurred, how it will be prevented from recurring, and an apology. Reported physician barriers to disclosure include: difficulty in admitting mistakes, fear of implicating others, possibilities of legal action, and the blame felt by physicians when an error has occurred. The authors note that Harvard University, the Veterans Health Administration, and JCAHO (among others) have provided outlines of: a) events that should be disclosed/communicated to the patient; b) how they should be communicated and in what contexts (what, who, when and where); c) documentation of the medical error; and d) support of error victims.
 


PHYSICIAN ATTITUDES
Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE. Disclosing medical errors to patients: attitudes and practices of physicians and trainees. J Gen Intern Med. 2007;22:988-996.

(For non-journal subscribers, an additional fee may apply for full text articles.)
View journal abstract No URL available for full article: Epub 2007 May 1
Kaldjian et al designed a cross-sectional survey of 538 faculty, resident and student physicians – pediatricians comprised 46% of faculty and 27% of residents – asking participants if they had ever a) made “a mistake that prolonged treatment/caused discomfort” or b) “caused disability/death,” and their disclosure of it. Participants were also presented with a hypothetical error vignette (with major, minor, or no harm response choices), and further, were asked to detail their beliefs about disclosure according to a taxonomy of facilitating and impeding attitudes. Forty-seven percent of respondents reported having made at least one minor or major error: 15% of faculty and residents reported a minor error that they disclosed and one they did not; 1% reported a major error they disclosed and one they did not; and 10% reported non-disclosure of an error due to legal liability (with 6% of faculty reporting attorney advice not to disclose). The researchers found that both actual and hypothetical disclosures were associated with feeling an obligation to disclose, as well as the belief that the decision to disclose did not depend on whether or nor it would help the patient. Actual disclosure alone was associated with the belief that disclosure alleviates guilt, while hypothetical disclosure alone was associated with the belief that disclosure is right (even at personal cost) because the respondent would want it and because it strengthens patient trust. Faculty were found more likely than trainees to disclose errors resulting in major or no harm. Of particular note, pediatricians were more likely than other physicians to disclose hypothetical error resulting in major or no harm and less likely to believe disclosure depends on if the information will help the patient. Those respondents believing forgiveness to be important were more likely to disclose hypothetical error with minor harm but were less likely to have disclosed an actual error with major harm. Further, litigation experience was associated with increased actual and hypothetical disclosure, although being a defendant was associated with actual non-disclosure of a disabling or fatal error.
 


PEDIATRICIAN ATTITUDES
Garbutt J, Brownstein DR, Klein EJ, et al. Reporting and disclosing medical errors: pediatricians' attitudes and behaviors. Arch Pediatr Adolesc Med. 2007;161:179-185.

(For non-journal subscribers, an additional fee may apply for full text articles.)
View journal abstract View full article
In an exploration of pediatricians’ attitudes toward and experience with reporting errors to hospitals and disclosure of errors, Garbutt et al performed an anonymous cross-sectional survey of 439 university-affiliated hospital and community pediatricians (50% in private practice) and 118 pediatric residents from St Louis and Seattle. Ninety-three percent of participants had been involved in a medical error. Pediatricians were asked about their beliefs and behaviors related to reporting, disclosure and collegial discussion of errors, their experience with formal and informal reporting of errors, features of systems that would increase willingness to report errors, and their beliefs and experiences regarding disclosure (eg, types of errors that should be disclosed, barriers to disclosure, and personal experience). While respondents endorsed reporting errors to the hospital (97%, serious; 90%, minor; 82%, near miss), only 39% thought that current error reporting systems were adequate. Most had used formal (‘incident report’ – 65%) or informal (‘telling a supervisor/senior physician’ – 47%/38%) methods of reporting errors, and 72% had discussed errors with colleagues. Respondents endorsed disclosing errors to patients' families (99% serious; 90% minor; 39% near miss), and many had done so (36% serious, 52% minor). Some respondents reported multiple barriers to disclosure, as well as a reduced likelihood to disclose an error if they perceived the family would not understand, was unaware, or would not want to know. Residents were more likely than attending physicians to believe that disclosing a serious error would be difficult (96% vs 86%) and to want specific disclosure training (69% vs 56%). The authors recommend formal and experiential training for residents to further educate them in open communication about errors
 


PARENTAL PREFERENCES
Hobgood C, Tamayo-Sarver JH, Elms A, Weiner B. Parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children. Pediatrics. 2005;116:1276-1286.

(For non-journal subscribers, an additional fee may apply for full text articles.)
View journal abstract View full article
In a study of parental preferences for error disclosure and reporting, a convenience sample of 400 parents of children presenting to a tertiary care academic emergency department were presented with 4 short vignettes of hypothetical events occurring to their children. These included:
  1. medication errors
    • 7-year-old with cancer chemotherapy overdose and subsequent lifelong dependence on dialysis
    • 8-year-old with seizure and diazepam overdose with subsequent recovery and no long-term problems
  2. failure to diagnose
    • 6-year-old with bacterial meningitis and subsequent permanent hearing loss
    • 5-year-old with sore throat subsequently diagnosed as strep throat leading to treatment and full recovery
The authors found that parents judged 54% of the scenarios as severe; 99% wanted disclosure; 39% wanted the error reported to a disciplinary body; and 36% were less likely to seek legal action if the error was disclosed by the physician. Of note is that African-American parents in the study were found more likely to judge an event as severe (62% vs 49%) and to choose to have an error reported to a disciplinary organization (50% vs 33%). This study supports that: a) parents universally want disclosure of pediatric medical errors regardless of severity, b) disclosure may reduce parental likelihood of seeking legal action except in severe errors, and c) increased (perceived) severity of medical errors is associated with increased desire for reporting to a disciplinary agency.
 


CASE STUDY:
MEDICAL ERROR RESULTING IN DEATH
Keatings M, Martin M, McCallum A, Lewis J. Medical errors: understanding the parent's perspective. Pediatr Clin North Am. 2006;53:1079-1089.

(For non-journal subscribers, an additional fee may apply for full text articles.)
View journal abstract View full article
This 2006 case study describes events occurring prior and subsequent to the death of Claire Lewis, an 11-year-old patient who died 3 days postoperatively in the Hamilton Health Sciences system, and includes discussion of associated system issues regarding the management of disclosure. After excision of a craniopharyngioma, the patient was transferred to an ICU in a different hospital (for pediatric care), but with a delay in transfer of her perioperative medical records. ICU management (without the records) led to fluid overload, hyponatremia, and catastrophic cerebral edema that caused her death. Review of the case revealed (among other issues) the need for staff refresher training in pediatric-specific postoperative care of craniopharyngioma (a relatively rare procedure), and the use of checklists and protocols. Initial failure by the physician and risk management team reviewing the case to address critical points (and to disclose to the family) led to a 4-month delay in senior management awareness of the problems, which contributed to distrust and anger by the family. Claire’s father, a nurse within the system, informed senior management of the system problems, which led to a subsequent decision for full disclosure and recommendations to implement reporting mechanisms. However, a similar death occurring within 1 year revealed that the recommended changes had not been made, resulting in additional
re-evaluation of how system changes were implemented and followed up. Subsequent full disclosure, apology, reconciliation with the family, and recommendations (plus follow up) for system, knowledge, and education changes were accomplished and are described by the authors.
 


FACTORS PROMOTING MALPRACTICE CLAIMS
Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA. 1992;267:1359-1363.

(For non-journal subscribers, an additional fee may apply for full text articles.)
View journal abstract No URL available for full article
Hickson et al performed a combined structured and open-ended telephone-administered questionnaire of families in Florida who had closed malpractice claims regarding infants who suffered permanent minor injuries (loss or damage to organs) or more, including death. Of 368 eligible families, 35% participated. The responses elicited provided information about medical care, physician-family communication, cost of injury, compensation, legal, and socio-demographic factors.

When asked about reasons for filing a claim, respondents most frequently reported (multiple reasons included):

(33%) influence from someone outside of the family (over half of those being physicians)
(24%) the need to pay for long-term care
(24%) the realization that the physician failed to be completely honest
(20%) the realization that the child would have no future
(20%) the need to “find out what happened”
(19%) a desire to deter the physician from further malpractice or for revenge

Most respondents complained about physician-family communication, reporting that the physician: would not communicate (32%), would not listen (13%), misled them (48%), and never informed them that their infant would have permanent problems or might die (70%). The authors’ note that physicians’ difficulties in communicating may arise from underestimation of parents’ information needs, parents’ need to review the same issues several times, and/or from their own personal discomfort. Recommendations included: contemporaneous records of what is said to parents and increased efforts to improve communication, including education of trainees.
 


THE ELEMENTS OF ERROR DISCLOSURE
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;22:755-761.

(For non-journal subscribers, an additional fee may apply for full text articles.)
View journal abstract View full article
In a qualitative analysis of focus group transcripts from 5 academic medical centers, (including hospital administrators, physicians, nurses and residents), Fein at al presented participants with a standard definition of medical error, followed by a hypothetical scenario of an inpatient error. Participants were asked if there should be disclosure, and if they believed the provider would disclose it. Providers were asked what steps and words they would use, while administrators were asked what they would expect to hear in a disclosure.

Transcript analysis revealed 6 elements of disclosure desired by patients:
  1. admission of an error
  2. discussion of the events of the error
  3. linkage of the error to an effect
  4. first effect of the error
  5. link between the error and any harm sustained, and
  6. explanation of the harm (and if it was communicated)

Five distinct types of disclosure were derived, based on the presence or absence of each of the above elements:
  1. Full disclosure
    (all elements present)
  2. Partial disclosure: connect-the-dots
    (discussion of events and explanation of harm)
  3. Partial disclosure: mislead
    (connect-the-dots with obfuscation of linkage of error to harm)
  4. Partial disclosure: defer
    (connect-the-dots with deference of linking error to harm)
  5. Nondisclosure
    (no elements present)

The authors provide examples and wording of each type of disclosure with regard to how it matches or does not match patient expectations, along with discussion of how this information may help create realistic guidelines for disclosure.
 


CME/CNE INFORMATION
 Accreditation Statement — back to top
Physicians
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Nurses
The Institute for Johns Hopkins Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Respiratory Therapists
Respiratory therapists should visit this page to confirm that AMA PRA Category 1 Credit(s)TM is accepted toward fulfillment of RT requirements.
 Credit Designations — back to top
Physicians
eNewsletter: The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Podcast: The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Nurses
eNewsletter: This 1.0 contact hour Educational Activity (Provider Directed/Learner Paced) is provided by The Institute for Johns Hopkins Nursing. Each newsletter carries a maximum of 1.0 contact hour or a total of 12.0 contact hours for the twelve newsletters in this program.

Podcast: This 0.5 contact hour Educational Activity (Provider Directed/Learner Paced) is provided by The Institute for Johns Hopkins Nursing. Each podcast carries a maximum of 0.5 contact hours or a total of 3.0 contact hours for the six podcasts in this program.

Respiratory Therapists
For United States: Visit this page to confirm that your state will accept the CE Credits gained through this program.

For Canada: Visit this page to confirm that your province will accept the CE Credits gained through this program.
 Post-Test — back to top
To take the post-test for eNeonatal Review you will need to visit The Johns Hopkins University School of Medicine's CME website or The Institute for Johns Hopkins Nursing or download a PDF of the post-test from the issue itself for Pharmacy. If you have already registered for another Hopkins CME program at these sites, simply enter the requested information when prompted. Otherwise, complete the registration form to begin the testing process. A passing grade of 70% or higher on the post test/evaluation is required to receive CME/CNE credit.
 Statement of Responsibility — back to top
The Johns Hopkins University School of Medicine and The Institute for Johns Hopkins Nursing take responsibility for the content, quality, and scientific integrity of this CME/CNE activity.
 Target Audience — back to top
This activity has been developed for neonatologists, NICU nurses and respiratory therapists working with neonatal patients. There are no fees or prerequisites for this activity.
 Learning Objectives — back to top
At the conclusion of this activity, participants should be able to:

Identify the key elements of complete error disclosure
Discuss the currently identified barriers to error disclosure
Explain the relationship between error disclosure and litigation
 Internet CME/CNE Policy — back to top
The Office of Continuing Medical Education (CME) at The Johns Hopkins University School of Medicine (SOM) is committed to protect the privacy of its members and customers. The Johns Hopkins University SOM CME maintains its Internet site as an information resource and service for physicians, other health professionals and the public.

Continuing Medical Education at The Johns Hopkins University School of Medicine and The Institute for Johns Hopkins Nursing will keep your personal and credit information confidential when you participate in a CE Internet based program. Your information will never be given to anyone outside The Johns Hopkins University program. CME/CE collects only the information necessary to provide you with the service you request.
 Faculty Disclosure — back to top
It is the policy of the Johns Hopkins University School of Medicine that the faculty and provider disclose real or apparent conflicts of interest relating to the topics of this educational activity, and also disclose discussions of unlabeled/unapproved uses of drugs or devices during their presentation(s). Johns Hopkins University School of Medicine CME has established policies in place that will identify and resolve all conflicts of interest prior to this educational activity. Detailed disclosure will be made in each issue of the newsletter and podcast. The Course Directors reported the following:

Edward E. Lawson, MD has indicated a financial relationship of grant/research support from the National Institute of Health (NIH). He also receives financial/material support from Nature Publishing Group as the Editor of the Journal of Perinatology.
Christoph U. Lehmann, MD has indicated no financial relationship with commercial supporters.
Lawrence M. Nogee, MD has received grant support from the NIH.
Mary Terhaar, DNSc, RN has indicated no financial relationship with commercial supporters.
Robert J. Kopotic, MSN, RRT, FAARC has indicated a financial relationship with the ConMed Corporation.

Guest Authors Disclosures
 Disclaimer Statement — back to top
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings and adverse effects before administering pharmacologic therapy to patients.
© 2007 JHUSOM, IJHN, and eNeonatal Review

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COMPLETE THE POST TEST

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Respiratory Therapists
Visit this page to confirm that your state will accept the CE Credits gained through this program or click on the link below to go directly to the post-test.