Spotlight Case

1. Spotlight Case Duty to Disclose Someone Else’s Error

2. Source and Credits • This presentation is based on the May 2011AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Thomas H. Gallagher, MD University of Washington • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • State the rationale for disclosing medical errors • Describe key principles in effective error disclosure • Appreciate that physicians are reluctant to criticize colleagues • Outline a process for disclosure of an error made by another institution

4. Case: Duty to Disclose (1) A 4-year-old boy presented to an emergency department (ED) with 3 days of vomiting associated with lethargy and fevers. He had been exposed to a child with strep throat the previous week but otherwise had been well until symptoms began. Examination revealed a low-grade fever and some redness in his throat. Laboratory tests were unremarkable, and a head CT was reported as normal by the radiologist. A rapid test for streptococcal pharyngitis was positive. He was admitted to the hospital and given intravenous hydration and antibiotics.

5. Case: Duty to Disclose (2) Over the next 24 hours, the child became increasingly confused, disoriented, and lethargic. The next morning, his condition worsened and he had a respiratory arrest. He was placed on a ventilator and transferred to the ICU. In the ICU, he was noted to have fixed and dilated pupils on neurologic exam, a sign of serious neurologic injury. A repeat CT scan of the brain revealed severe cerebral edema (swelling of the brain) with evidence of herniation of the brain through the base of the skull.

6. Case: Duty to Disclose (3) He was transferred from this hospital to a tertiary care center for ongoing management. At the tertiary care center, the child was evaluated by neurology and neurosurgical teams. Further testing revealed a diagnosis of venous sinus thromboses (blood clots in the veins of the brain), which had led to edema and herniation. The brain damage was advanced and the child was determined to have no chance to survive.

7. Case: Duty to Disclose (4) As part of their routine evaluation, neurology, neurosurgical teams, and radiologists at the tertiary care center reviewed the CT scan from the original ED. Although the findings were subtle, they found that the scan demonstrated clear evidence of cerebral edema. The initial hospital had not recognized these findings nor pursued further work-up for the cause. The neurology and neurosurgical teams felt that if the brain swelling had been recognized at that time, the child could have been transferred earlier, received surgical management, and might have survived.

8. Case: Duty to Disclose (5) When it was clear the child could not survive, the pediatricians met with the mother and father to explain that their child was brain dead. Angry and upset, the parents asked repeatedly, “How could this happen? How could the CT scan have been normal and then be so bad in less than 48 hours?”

9. Case: Duty to Disclose (6) Due to concerns of legal liability, hospital administration and risk management at the tertiary care hospital instructed the physicians and other providers to not disclose the misinterpretation of the original CT scan. In fact, they were instructed not to comment on the care provided by the initial hospital in any way. Therefore, the parents were never told that an error had been made that may have contributed to their child’s death.

10. Background: Error Disclosure • Discussing medical errors with patients is challenging • Patients want to know when errors have occurred in their care • Early disclosure combined with offers of compensation may help resolve challenging cases involving errors See Notes for references.

11. Rationale for Disclosure • Error disclosure is founded on ethical principles • Disclosure may help patients make more informed decisions about their health care • Disclosure respects patient autonomy • In general, patients want to learn about harmful errors that have occurred See Notes for reference.

12. Preparing for Disclosure • Disclosure of errors is complex and should be customized for each patient • There are key principles and a stepwise process for effective error disclosure

13. Key Steps in Error Disclosure • Get ready – know the facts of the case, be prepared to answer questions • Set the stage – find a suitable quiet room, avoid distractions • Listen and empathize – assess patient’s understanding of what happened, provide support • Explain the facts – identify the adverse event early, explain clearly what happened

14. Key Steps in Error Disclosure (2) • Apologize – say you are sorry in a sincere manner early in the conversation • Explain responsibility – explain your role, avoid blaming others or the “system” • Close the discussion – discuss next steps, provide contact information for other questions

15. Case-Specific Challenges • Additional factors complicate this case: • The disclosing physicians did not make the error • The error occurred at another institution (under the care of other providers) • There is some uncertainty about exactly what happened

16. Errors of Other Providers • Little evidence regarding disclosure of errors that other providers have made • Patients would likely still desire full disclosure under these circumstances • The culture in medicine has long been to avoid openly criticizing or policing colleagues

17. Physicians Reluctant to Criticize • In a survey of 1900 US physicians, 17% had direct personal knowledge of a physician colleague who is incompetent to practice medicine • Only 67% had reported this colleague to the authorities

18. Disclosure as a Team • Disclosure has traditionally been viewed as responsibility of an individual physician • However, care may be delivered by numerous providers, sometimes across institutions • Error disclosure is best viewed as the responsibility of the team—all providers involved in the care of a patient • In this case, team would include the referring providers

19. Process for Complex Disclosure • If another provider or institution has committed an error, a number of steps should be taken: • In conjunction with risk management at both hospitals, providers should have an open conversation about the care provided • Examination of the possible error might involve a root cause analysis • If an error occurred, ideally disclosure would be collaborative

20. Barriers to Collaborative Disclosure • Divergent self-interests in the malpractice insurers of both parties • Those involved might worry about specific legal ramifications • Careful planning of these conversations can minimize these concerns • These collaborative approaches are being tested through ongoing AHRQ projects

21. Disclosing Another’s Error • No consensus on what situations merit mandatory disclosure of another provider’s error • Might be important when such information would help a patient avoid future harm • For events like this case, no clear standard exists • However, leaving disclosure completely to the discretion of involved clinicians may be problematic

22. Recommendations • Ideally, a neutral third party (such as an ethics committee) would consider cases involving disagreements between providers about disclosure • Taking an institutional approach to complex cases involving communicating about another health care worker’s error can help ensure that these challenging but important conversations meet patient and family needs

23. In This Case • The two hospitals should have had an open dialogue about the case • If they determined that a clear error occurred, providers should have found a way to disclose the error openly and honestly to the parents • This outcome would have been ethical, collaborative, and patient centered

24. Take-Home Points • Although patients strongly favor hearing about medical errors in their care, providers often do not disclose • Clear disclosure of medical errors is ethical, respects patient autonomy, and may allow for better informed decision-making

25. Take-Home Points (2) • If other providers have committed an error, optimal strategies involve full collaboration in error investigation and joint disclosure if an error did occur • Hospitals should consider instituting disclosure policies and utilizing a neutral third party such as an ethics committees to mediate the most challenging disclosure cases