Disclosure of Medical Errors

Educational Objectives

The goal of this program is to improve disclosure of medical errors in clinical practice. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate between the various types of medical errors that occur in clinical practice.
2. Integrate various techniques for overcoming barriers in the disclosure of medical errors to patients and their families.

Summary

Medical errors in surgery: Ernest Amory Codman was the first to introduce the principle of errors and their outcomes in medicine based on operative morbidity; he classified errors based on the lack of, eg, technical knowledge, surgical judgement, care; in his book, Charles Bosk suggested that talking about medical errors and their outcomes functions as a form of social control to get the people to admit their mistakes and continue to improve; according to Bosk, 4 types of errors exist, ie, errors in technique (somewhat forgivable), errors in judgement (can demonstrate a lack of ability to think through processes properly), normative errors (errors of protocol; more common in surgery), and quasi-normative errors (errors of protocols specific to an individual; more common in medical practice); multiple algorithms are developed to prevent errors, but they still exist; errors are also identified based on whether the outcome was bad or foreseeable, or the error was a near-miss or a “harmless hit”

Defining medical error: The Joint Commission — defines error as an unintended act of omission or commission, or an act that does not achieve its intended outcome; Institute of Medicine — defines error as failure of a planned action to be completed as intended, error in execution, or use of an incorrect plan to achieve an aim; Albert Wu — defines error as commission or omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were negative consequences (excludes the natural history of disease that does not respond to treatment, foreseeable complications of a correctly performed procedure, or when there is reasonable disagreement over whether a mistake has occurred)

Disclosure of errors: defining what constitutes an error is important in terms of full disclosure policies; various ethical schools of thought consider the person performing the act, the act itself, or the outcome

Virtue-based ethics: calls for development of virtuous habits (eg, honesty, compassion, fidelity, technical excellence) and avoidance of vicious behavior; developing the virtue of honesty entails developing a habit of telling the truth, avoiding prevarication, and following the policy of transparency

Act-based theory (Immanuel Kant): considers the act itself; emphasizes acting out of a duty to respect the dignity of the individual and honesty as fundamental for trust; Kant developed 2 formulations; people should always be treated as “ends” in themselves and never as “means to an end”, eg, lying to someone is treating that person as means to an end because their inherent dignity is not being valued; according to the American Medical Association Code of Ethics, it is a fundamental duty and requirement to deal honestly and openly with all patients; the physician is also ethically required to inform the patient of all facts necessary to ensure and understand what has occurred; specifically with error disclosure, concern about legal liability should not affect a physician’s honesty

Utilitarianism: Jeremy Bentham and John Stuart Mill explained that human actions are based on maximizing pleasure and minimizing pain; when assessing the consequences of a certain behavior, the physician should prioritize the consequences to the patient over the consequences for themselves; errors should be disclosed; evidence also shows that disclosing errors may lead to less malpractice lawsuits; in 2001, the University of Michigan developed a policy of full disclosure and offer of compensation, and found a decrease in lawsuits and costs

Barriers to full disclosure: disclosure can lead to negative personal consequences, eg, receiving poor evaluations, or failure to progress, loss of referrals, damaged reputation, and potential lawsuits; other barriers include the philosophical, uncertain nature of errors, and poor communication skills; the culture of medical narcissism can impact the physician’s psychological wellbeing

Techniques for disclosure of errors: agree on what happened; if a physician is involved in a medical error, contact risk management for confirmation of the nature of the error; contacting the risk management team triggers an investigation for root cause analysis; decide who should be present when discussing an error; in a teaching hospital, this would likely include the attending physician, residents, and the patient and their family; this should be addressed in person and in a quiet room; try to minimize distractions, sit down, and engage with the patient and their family; specifically describe and discuss the error, harms that occurred, and consequences of the harm, and offer an apology; describe the actions that will be taken to diminish the gravity of the harm and methods to prevent its occurrence in the future; describe who will manage the patient’s continuing care; offer to transfer the patient to another physician if the error has broken the relationship with the patient and their family, ie, they no longer trust the physician; identify the system elements of error and assure the patient and family that the associated cost of the error will be removed; avoid medical jargon and obfuscation

Readings

Begley AM. Truth-telling, honesty and compassion: a virtue-based exploration of a dilemma in practice. Int J Nurs Pract. 2008;14(5):336-341. doi:10.1111/j.1440-172X.2008.00706.x; Garbutt J, Brownstein DR, Klein EJ, et al. Reporting and disclosing medical errors: pediatricians' attitudes and behaviors. Arch Pediatr Adolesc Med. 2007;161(2):179-185. doi:10.1001/archpedi.161.2.179; Leopold SS. A Conversation with … Charles L. Bosk PhD, Expert on Surgical Education and Medical Error, and Author of Forgive and Remember: Managing Medical Failure. Clin Orthop Relat Res. 2020;478(6):1147-1151. doi:10.1097/CORR.0000000000001184; Rodziewicz TL, Houseman B, Hipskind JE. Medical error reduction and prevention. StatPearls Publishing. 2023 May 2. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499956/; Wolemonwu VC. Richard Dean: The Value of Humanity in Kant's Moral Theory: Clarendon Press, Oxford, 2006, pp. x + 267. Cloth, £28.12. Med Health Care Philos. 2020;23(2):221-226. doi:10.1007/s11019-019-09926-2; Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-727. doi:10.1136/bmj.320.7237.726.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Vercler was recorded at 39th Annual Update in Internal Medicine, held July 28-30, 2023, on Mackinac Island, MI, and presented by University of Michigan School of Medicine. For information about upcoming CME activities from this presenter, please visit https://michmed.org/intmedcme. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

IM704302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.