The move to disclose medical error
Paul A. Raslavicus, MD
It is an axiom that painful transition is a prerequisite for meaningful
change. This is true of organizational change as well as of life passages.
It is also true of social and economic movements. Changes occurring
now in the culture of our health care system suggest that the issue
of medical liability is in this type of transition.
We have heard much about patient safety, sentinel
events, and systems error, which are the themes of
two monographs published by the Institute of Medicine's Committee
on Quality of Health Care in America. Both documents, titled To
Err Is Human: Building a Safer Health System and Crossing the Quality
Chasm: A New Health System for the 21st Century, propose sweeping,
systemic changes and have sent ripples across the profession.
To Err Is Human, the major goal of which was to end what
it termed a "cycle of inaction" about patient safety and medical
error, generated far more publicity than the second, though the
latter covers more ground. Crossing the Quality Chasm calls
for broad-based health systems improvement in six areas: safety,
effectiveness, patient-centeredness, timeliness, efficiency, and
To Err Is Human put patient safety and medical error on the Sunday
morning talk shows, but it is the new Joint Commission on Accreditation
of Healthcare Organizations standard requiring that patients and
families be "informed about outcomes of care, including unanticipated
outcomes," that brings the story home. We in the practice of pathology
serve patients, and when failures occur in the provision of our
services, we are all affected by this standard. This, of course,
applies to problems of transcription, misidentification, or misinterpretation
in the clinical laboratory as well as matters of misinterpretation
when dealing with tissues or cells.
Many of us have been raised in the tradition of paternalism, where
the patient is told only what she or he needs to know. We tend to
look in horror at this new standard, which seems to be, at best,
an invitation to higher levels of liability risk. Yet there is a
positive side. For many of us, this new policy is in concert with
our personal ethic of being truthful with those who entrust us with
their care. This standard, too, without question, is consistent
with the patient empowerment movement that is sweeping the country.
Appropriate disclosure also is important to preserving patient relationships
that could otherwise disintegrate, improving outcomes for others
by prompting systems improvements, and helping patients form more
realistic expectations of a system that, as we all know, is not
Preliminary evidence suggests that voluntary disclosure does not
lead to an increase in liability lawsuits. When settlement does
take place, the monetary payments are often lower. This is so in
part because prompt and considerate disclosure defuses anger, and
in part because lawyer fees and hyperbole are minimized.
Better settlement outcomes can also be attributed to the development
and teaching of the art of appropriate disclosure methods, which
are based on the science of effective negotiation and conflict resolution.
The method calls for sensitivity to the setting and the participants,
and, most important, to the oral communications employed. Physicians
need to listen closely to patients and families during the post-incident
encounter, should not hesitate to show sympathy, and should understand
the difference between an apology and an admission of liability.
Saying "sorry" can go a long way. Careful speech and thoughtful
listening are key to achieving satisfactory resolution of untoward
The best medicine, of course, is to prevent error. The College
sponsored a Virtual Management College series on medical error earlier
this year, which addressed systems-based approaches to counter human
fallibility. Speakers explained the rationale for a culture centered
on collective responsibility for patient safety, and they challenged
conventional "blame and shame" thinking. Human fallibility is a
given, they explained, but other enterprises have demonstrated that
good systems can minimize mistakes and prevent oversights. Errors
are consequences, not causes, said Lee H. Hilborne,
MD, MPH, in his presentation for the first workshop on Feb. 12.
We can engineer safety into the system, Ronald L. Sirota,
MD, declared at the second VMC a month later. We can create protective
systems as well as productive systems.
The College will sponsor a third program on errors in surgical
pathology at the U.S. and Canadian Academy of Pathology meeting
on March 3, 2003.
Fears about disclosing errors in care are rooted in fear of legal
action, a concern that is being addressed by a bipartisan bill now
before Congress. The Patient Safety and Quality Improvement Act,
introduced in June, would create a medical errors reporting system
made up of independent patient safety organizations that would analyze
reports of untoward events and give feedback on how to fix problems.
Information reported voluntarily for quality improvement and patient
safety purposes would be held privileged and confidential.
The House version of the bill, sponsored by Rep. Nancy Johnson
(R-Conn.), includes an excellent section on informatics. This version
would create a medical information technology advisory board to
advise the secretary of Health and Human Services on the best practices
in medical information technology and methods to implement them.
This legislation recognizes, as does the IOM, that greater attention
to information technology can eliminate much of the medical error
that is inherent in the system. Crossing the Quality Chasm
calls for eliminating most handwritten clinical data by the end
of the decade. This clear commitment to modern medical informatics
is the way to go.
As pathologists, we work with a cross-section of specialists.
Being dedicated to the clinical laboratory, we are comfortable with
systems approaches, at home with quality assurance and quality improvement
mechanisms, and appreciate the value of sound data analysis. As
respected leaders in medical quality management, we are ideally
prepared to take the lead in shaping a new culture of collective
responsibility for quality in our hospitals. Continuous quality
improvement in patient care and the application of top-quality laboratory
informatics have been the hallmarks of our specialty and drivers
for many of the CAP's activities, including such premier services
as Q-Probes, Surveys, and SNOMED, the universal vocabulary for medicine.
Suddenly, our longtime ideals have become a necessity for all of medicine.
The need to develop efficient communication systems, methods for
error analysis, and systems adjustments are all proper places in
which our long-honed skills can be used effectively. Let us put
our knowledge to work for the common good.