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Medical Errors Hospital

Disclosure of Medical errors in every day clinical practice.

Introduction

Medical errors are very common in every day clinical practice. Even taking serious caution does not make the error free hospital any where in the world. According to British Medical Journal ( cited in Adams 2005), “about 850,000 medical errors occurs in National Health hospitals every year resulting in 40,000 deaths…. Adverse events occur in 10% of all hospital patients" (p. 274). Today’s times 2004 ( cited in Adams 2005) claims a cost of 2 billion pounds per year due to medical errors. The data shows the magnitude and the significance of the problem. In fact medical errors are preventable in most of the cases. But the sad part of the story is these errors are not disclosed to the patients or the family. Disclosure of medical errors is a very big issue for the leadership and management of a hospital in terms of institutional ethics. This paper will discuss about medical errors, the issue of its disclosure , its outcomes, current trends regarding disclosure of errors, application of theories and implementation in our context.

Medical Errors

Albert , Cavanaugh, Mc Phee , Bernard , and Micco ( 1997) define medical error as “Commission or omission with potentially negative consequences for the patient that have been judged wrong by knowledgeable peers at the time it occurred , independent of whether there were any negative consequences” (p.770). In this regard understanding of the error and realization that it is an error is very important. The issue is if it is internalized that error has occurred, then should it be disclosed or not.

Non disclosure of medical errors

There is a very strong culture of a number of hospitals world wide and the hospital where I belong to that health care professionals hide and do not disclose medical errors to the patients or their families. Errors come on the picture if by any means the patient or their family comes to know about the error. Kaldijan ,Rosenthal, Reimer, and Hillis (2005) did literature review of 316 articles on medical errors and came up with four categories which include attitudinal barriers, helplessness from the institution, uncertainties about how to disclose and its outcomes, and fears and anxieties. In addition to it, risk of ruining person’s as well as the hospital’s reputation, legality issues, low self esteem in the profession, mistrust of the patient and the family, and hindrance in professional progress are also some of the very important barriers to disclosure. (Boyle, Connell, Platt, Albert 2006, Fischer et al 2006, Albert et al 1997). Besides organization’s culture, policy and the colleagues’ attitude also impacts error disclosure.

Non disclosure of errors can have some beneficial effects for the patients as well as for the physician. Patients do not become emotionally upset on hearing the news of occurrence of unexpected event during the hospitalization. Boyle, Connell, Platt, and Albert (2006) have cited that American college of physicians has given the liberty of not disclosing the error if the disclosure can cause more harm than benefit as in the case of psychiatric or depressed patients. But the worse part of it is this concept of deception for the benefit of patient is misused in the name of the health care personnel own interests. Similarly risk benefit ratio of disclosure should be calculated or in ethical terms beneficence versus non maleficence should be judged. Furthermore health care personnel do not have to fear for legal issues and the reputation. However they suffer emotional distress if they do not disclose.

Disclosure of Medical Errors

Medical errors should be disclosed as an ethical and moral responsibility of the health care personnel and the institution as whole. JCIA and JCAHO has made it a standard in 2001 that disclosure of errors should be implemented in hospitals. (Connell, White, Platt 2003, Henry 2005, Gallagher, Studdert, Levinson 2007). In addition The code of ethics of American Medical Association, The American College of Physicians and the National Safety Foundation have also emphasized on disclosure of errors.( Boyle, Connell, Platt, and Albert 2006 ). The standardization of disclosure by so many international organizations particularly JCIA and JCAHO gives the message that the culture and the approach towards the issue of disclosure is changing. These bodies are international standardized bodies and the change in the approach must be evidenced based. If disclosure was not that important it would not have been the part of these quality improving bodies.

Literature supports disclosure of errors. According to Connell, White, Platt (2003) , response of participants who attended the workshop about disclosure of medical errors was 90% affirmative . In a study done by Hobgood, Peck, Gilbert, Chappell ( 2002) on patients and their familys’ perspective of error disclosure gave interesting results. 258 surveys were filled in an emergency department and it revealed that 76% of patients wanted disclosure in case of any error, and 88% felt to its full extent. This clearly indicates the significance of disclosure as an issue and patients need regarding the issue.

Disclosure of medical errors has many benefits. Initially the reaction of patients may be negative as error could never be expected from patients’ side. But later they get settled .Studies show positive outcomes from patient as well as the health care personnels’ angle because of disclosure. Error disclosure helps patients to get any compensation in the form of additional treatment or financial help. Most of health care personnel believe that disclosure can ruin their relationship with patients and can bring law suit as well as their image down among their collegues. However according to Witman ( cited in Boyle, Connell, Platt, and Albert 2006 ) patients felt to claim law suit if they were not disclosed about errors. In addition University of Michigan Health System reported that “ the cost and frequency of litigation decreased substantially in 5 years after implementation of an open disclosure programme , with annual litigation …reduced from $3 million to $1 million and … claims by more than 50%” ( Gallagher, Studdert, Levinson 2007 p. 2716). Error disclosure also brings a positive impact on learning for the person who did the error as well as for others in the organization. Hence mistakes done once may not be repeated next time , system improvement and therefore improvement in the quality of patient care. ( Albert 1997, Mazor 2005, Boyle, Connell, Platt, and Albert 2006 ). Moreover patient physician relationships do remain intact in most of the cases.

Trends in application of disclosing errors and comparison in our context

Disclosure of medical errors is gaining its significance in so many health care organizations because of the outcomes of it as well as the realization of doing disclosure. Gallaher, Studdert, and Levinson ( 2007), have stated that 2002 survey of institutional risk mangers showed that 36% of the institutions have adopted disclosure policy and the percentage increased to 69% in 2005. They further quoted that Austarlia and United Kingdom in 2003, National Quality Forum safe practices and Harvard in 2006 emphasized and provided guidelines for full disclosure of medical errors to patients. The trend shows that awareness for disclosing medical errors is gaining its popularity.

If we compare the scenario in Pakistan, we have a culture of not disclosing errors in most of the hospitals. In addition to the reasons discussed in the literature regarding non disclosure of medical errors, most of the times it is taken as for granted by the health care professionals that the patients belong to low socio economic status, less educated, low level of understanding and therefore errors need not be disclosed. It has been observed in clinical practices that errors are considered most of the time as side effects and untoward result because of certain treatment and there is no internalization that it is an error. In addition there is also a misconception that since the error did not bring any harm to patient so need not to be reported to the hospital management team and therefore no disclosure to the patient. It is interesting to know that most of the hospitals in Pakistan do not have any policy for disclosing error. However in Aga Khan University Hospital (AKUH) the policy for disclosure of errors exists and it is mentioned in the sentinel events policy that there should be disclosure of medical errors and it is mentioned in the patients’ bill of rights that patients have right to have all information .( Multi disciplinary policies and procedures sentinel events policy no: MDP-S-002). But the sad part of the story is there is no proper implementation of the policy as well as proper explanation of patients’ rights to them. In fact there is no such culture for the individual to share errors to their supervisors as an ethical and moral responsibility until the error is identified by someone else.

Reviewing the issue in the light of Theories

To support that medical errors should be disclosed, we will be utilizing the following theories of ethics as well as leadership and management.

Kant’s Theory of Deontology

Immanuel Kant a German philosopher has given the theory of deontology or duty based theory. According to Kant (cited in Bernstein and Brown 2004), act should be done on the basis of the duty or obligation regardless of the consequences. He also believed that the intention behind the act justifies the action done. If we try to understand the disclosure of medical errors from Kant’s perspective, disclosure should be done as it is the duty of the health care personnel. It is the right of the patient and duty of the personnel to share all information including the errors if occurred. Kant believes in telling the truth which is the duty in all conditions and deception is un tolerable. The debate that if truth telling causes harm should be told to patients or not , goes against Kant’s philosophy. If health care professional feels that deception of the truth will give more benefit than there should be a very strong rationale for it and should not be taken as for convenience. Kant (cited in Bernstein and Brown 2004) has discussed about one’s conscience which play a major role in making right decisions according to his duty and states, “consciousness is an internal court …before which a human being’s accuse or excuse one another…an internal judge, and this authority watching over the law in him is something that he himself makes, but …incorporated in his being” (p.172).

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Heifetz’s perspective on Ethical leadership

Heifetz ( cited in Northouse 2007) explains that leaders help followers to help resolve conflicts by using their authority. He further explains that “Heifetz’s perspective is related to values of workers, organizations and communities in which they work” (p. 347). In the light of this perspective, leaders need to have a clear idea of what is the value of the organization which in all circumstances is the best quality care given to its customers and taking care of their wishes and doing what is right. Leaders need to persuade people to do the right thing and therefore the culture of disclosure of medical errors should be inculcated by the leaders.

Burn’s perspective on Ethical leadership

Burns gave the theory of transformational leadership in 1978. According to Burns (cited in Northouse 2007), leaders have an important role in motivating people to identify their values and to help them reach to a level where the principles of “justice, liberty and equality” should be incorporated in practice. This clearly indicates the moral aspect of leadership which leads that disclosure of errors should be done as moral obligation of the organization.

Significance of medical error disclosure from leadership and management perspective

The issue of medical errors disclosure is very important from leadership and management point of view because this issue is not confined to a particular institution but it is a global issue. As discussed above that leaders have a very important role in pursuing and motivating people to follow morality in practice. Ethics has a very important place in leadership and organization. Leaders give direction to the followers or subordinates. They have a very strong impact on their followers. Therefore if leaders will have strong value on creating an environment and culture whereby every individual gets rights and do their duties, then this gives rise to an organization following ethical principles. This is only possible if and only if the leader values that act. In the issue of medical errors disclosure, leaders should play their role to first get the issue internalized and get it inculcated in the organization’s culture.

Implementation of disclosure of errors in our context

In order to address the issue in our Pakistani and in particular AKUH the most important aspect is first internalizing that the error occurred and not getting defensive. Internalization can be done by leading seminars, discussions, conferences and bioethical grand rounds where issues of error disclosure can be discussed and health care professionals can clarify their misconception about errors. They should have a very clear understanding of what are medical errors. Once the understanding of error is there, the next step is reporting of errors in the organization through the in built system of error reporting. Unfortunately AKUH Karachi does not have a very good system of error reporting. Errors are reported when someone identifies it but the person involved rarely reports the error. On conversation with clinical affairs person of AKUH , centralization of errors reporting is under process. At present if errors are reported it is not centralized to one place. Centralization will assist in getting the picture of medical errors occurring in the hospital as a whole.

There should be reinforcement at the academia level of medical and nursing education about errors and its disclosure .Adams ( 2005) has given a very practical approach towards identifying our own errors. He has shared his example how he started writing all the errors which he identified during his practice and it was interesting to see that the identified errors were between one to six per week for 29 weeks . This data was for those errors which he identified himself and may not have captured all the errors done. This practice will help us identify and internalize that how many errors are made by health care professionals. Besides , voluntary electronic reporting of medical errors can also be implemented . The results of one study where 92,547 reports from 26 hospitals were evaluated showed that 47% of the registered nurses did voluntary reporting of errors compared to intern doctors which was 1.4%.( Milch, et al 2006). Jones, Cochrane, Hicks and Mueller ( 2004) asserts that success of voluntary error reporting depends upon the organizational culture where confidentiality is maintained and a “non punitive culture” exists which promotes error reporting.

Once the error is reported, the question comes for the disclosure of error. Henry (2005) asserts that there should be clear policy for disclosure and this helps in creating an open organizational culture for disclosure as well as promotes patients autonomy. He further adds that managerial support should be there and as leaders they should be promoting disclosure in their organization. Organization’s culture needs to be formulated which best supports the disclosure policies. Giganti( cited in Henry 2005) claims that “ one must approach culture change with systems thinking….organization’s culture is built up over time and is based on the assumptions , beliefs and values that drive the organization” (p. 132). Hence the cultural change involves evaluation of systems to see why there is hesitancy and reluctance in disclosing errors to patients and their families. Persons should not be blamed instead system should be analyzed .Cultural change at the institutional level will lead the policy makers to consider it at the health ministry level because there needs to be law to address this issue.

Disclosure is not an easy task keeping into considerations the so called consequences afterwards. There needs to be special trainings in this aspect. Hobgood, Hevia and Hinchey ( 2004) suggest for disclosure in terms of promoting safe environment to the patients and that there should be open conversation during disclosure expecting any reaction from the patient. Therefore communication plays a very important role. Furthermore Connell, White and Platt ( 2003) have given the steps for error disclosure which includes “ apologize and take responsibility”, “determine who will be involved”, and “be proactive in addressing the patient’s financial needs” (p.27). However the concept of becoming proactive in identifying our system gaps and root cause analysis of the problem will promote a safety culture and hence less medical errors and therefore less issues of disclosure.

Conclusion

Medical errors cause huge number of deaths which can be prevented. Medical errors do occur every day in our clinical practices but there is under reporting of the errors. And if reported there is culture of non disclosure of errors until it comes to patient’s knowledge by any means or the outcomes of that error are such that it cannot be kept hidden. The reasons identified through experiences and literature are fear of destroying relationships with patients, loss of patients trust on heath care personnel, legal issues , loosing the credibility in the profession, shame , guilt and not realizing to disclose considering it better from patients perspective. However recent trend suggests that institutions who developed and implemented disclosure policy had very positive results . Patients felt that they were apologized for that and were brought into confidence. This led to less law suits and decrease in the cost given for legal issues. Besides patients were able to participate in the compensation or adjustment for the loss due to error. Hence the above mentioned literature and practical experiences suggest that medical errors should be disclosed. Leaders need to help their subordinates or the followers to apply Kant theory of deontology but justify if they feel error should not be disclosed. Moreover it is the responsibility of the leader and each and every individual of the team to help creating an open environment of disclosure and to follow it.

References

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Berstein, M. & Brown, B.(2004). Doctors’ duty to disclose error: a deontological ethical analysis. The Canadian Journal of Neurological Sciences,31, 169-174.

Boyle, D., O’Connell, D., Platt, F. W., & Albert, R. K.(2006). Disclosing errors and adverse events in the intensive care unit. Critical Care Medicine,34 (5), 1532-1537.

Connell, D. O., White, M. K., Platt, F. W. (2003). Disclosing unanticipated outcomes and medical errors. JCOM, 10(1), 25-29.

Fischer,M. A., Mazor,K.M., Baril,J., Alper, E., Demarco,D., & Pugnaire,M. ( 2006). Factors that influence how students and residents learn from medical errors. Journal of General Internal Medicine , 21, 419-423.

Gallagher, T. H., Studdert, D., & Levinson, W. (2007). Disclosing harmful medical errors to patients. The New England Journal Of Medicine,356, (26), 2713-9.

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Hobgood, C., Peck, C. R., Gilbert, B., Chappel, K., & Zou, B. (2002). Academic Emergency Medicine, 9(11), 1156-1161.

Jones , K. J., Cochran, G., Hicks, R.W., Mueller, K.J.( 2004). Translating research into practice: voluntary reporting of medication errors in critical access hospitals. The Journal of Rural Health, 20 (4), 335- 343.

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