I’ll set the stage for talking about so-called open disclosure of medical error with four observations on the patient–physician relationship—ones that I hope we hold in general agreement:
- Trust is the foundation of the patient–physician relationship
- Honesty, benevolence, compassion, and competence all advance that trust
- Social science research has shown that broken trust is easier to rebuild when it is caused by a failure of competence than by perceived failure of honesty
- Adverse events and harmful medical errors erode trust in the patient–physician relationship because they raise questions about the competence and honesty of clinicians.
A change in how error is disclosed
Historically, harmful medical errors were not widely or openly discussed in health systems. Patients often received a highly edited version of events that led up to an adverse outcome or medical error. There is developing recognition by physicians and patients, however, that adverse events and harmful medical errors should be discussed openly and, in many cases, reported to authorities.1,2 And along with the recognition that disclosure is important have come better processes for communicating and recording adverse events and medical errors.
Questions from the medical team and the patient
A major adverse event or a harmful medical error raises two major questions for the care team to ask itself:
- How do we continue to best care for the patient who was harmed?
- How do we discuss and explain the events that preceded the harmful event?
Because the patient has been injured, optimal clinical care must continue to maximize the potential for full recovery; at the same time, the patient, or her family, may begin to ask: “How did this happen?” and, more challenging, “Was this injury preventable?”
A physician who is asked these questions may feel she is being placed in an awkward position: She needs to provide care and answer the patient’s questions while also gathering more information about the event and caucusing with her clinical team to prepare for disclosure.
Just the facts—for now
At the inquiry stage of the disclosure process, the physician should, as needed, provide nonjudgmental, factual information to the patient and her family. Refrain from speculating on the cause–effect relationship of events that preceded the injury until the opportunity arises for the clinical team to review the situation, agree on the facts of the case, and prepare a disclosure plan. It is best, for the moment, for the clinician to respond to the question “Was this injury preventable?” by stating that a detailed answer will be given once the case is reviewed by the care team. As rapidly as possible, the clinical team needs to meet: to identify the pertinent facts, to judge if an error occurred, and to then prepare to disclose the error.
Adverse event An unfavorable or negative outcome that may have been anticipated and that may or may not have been caused by an error.
Medical error A clinical action that experienced and well-trained peers would judge to be wrong and that may or may not result in an adverse event.
Unanticipated outcome A clinical result that is very different from what was expected to occur during the course of diagnosis or treatment.
Go stepwise in preparing for disclosure
Here are some key steps when you prepare for a disclosure meeting:
- Finalize which details will be disclosed and how they’ll be presented
- Identify who on the clinical team will lead communication with the patient and her family (most often, this task falls to the attending physician)
- Find an appropriately sized, quiet place to hold the meeting
- Decide who will attend: The patient (if she is well enough)? Her family? Other clinicians on the team?
- Explore which approaches to disclosure are most likely to sustain a supportive and mutually respectful environment.
Executing these steps takes a great deal of time and effort. But the effort increases the likelihood of successful and constructive disclosure, which best protects the trust between patient and clinicians.
What’s the recipe for “full and open disclosure”?
The elements of full and open disclosure include:
- clear description of the mistake that was made and the harm that occurred
- thorough discussion of the nature of the mistake
- identification of a clear cause–effect link between the mistake and any harm that followed.