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• Make Errors Transparent
  Ediriweera B.R., Desapriya
  Published on: 4 April 2005
• Not all error-prone doctors belong in Dante's Inferno!
  Daniel K Sokol
  Published on: 8 February 2005

• Published on: 4 April 2005

  Make Errors Transparent

  • Ediriweera B.R., Desapriya, Research Associate
  • Other Contributors:
    • Pike, I., Assistant Professor- Department of Pediatrics

  Dear Editor,

  Make Errors Transparent is necessary to reduce future medical errors and we strongly agree with Berlinger and WU. We need to change the culture and habits of health care so that errors and patient injuries are immediately known and reported - not to punish people, but to find ways to prevent their reoccurrence.

  Although a number of measures to reduce errors were proposed, a key strategy inv...

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  Dear Editor,

  Make Errors Transparent is necessary to reduce future medical errors and we strongly agree with Berlinger and WU. We need to change the culture and habits of health care so that errors and patient injuries are immediately known and reported - not to punish people, but to find ways to prevent their reoccurrence.

  Although a number of measures to reduce errors were proposed, a key strategy involved the use of reporting systems to identify and learn from errors [1]. Promoting patient safety is a international priority [2]. Health-care providers' own discussions of adverse events can be a good source of data for proactive error prevention. Safe medical practices can be more easily achieved if medical staff recognizes the benefits of reporting, discussing, and learning from errors. Practice safety relies on a greater safety culture within organizations.

  But overall, error-reduction in health care often continues to blame individuals, rather than examining systems, hence often fails to detect or correct underlying systems failures when errors occur. One important problem in assessing the frequency of errors is that we are deeply immersed in a blame culture, so it is hard to persuade people to report them. If we are to learn from mistakes then we need to know about as many as possible so that corrective action can be taken. This requires a cultural change and sensitive handling of the individual making the report.

  Capacity of reporting analyzing and learning from experience is still seriously hampered by fear of professional liability [3]. The risk of litigation and costly settlements has further discourage disclose information about errors. Changing the culture of medicine to increase reporting of errors is central to current efforts to reduce future error in health care. To change the culture of medicine we need to change legal culture of litigation. Improvements should be made to our medical liability system - improvements that can substantially reduce meritless claims and defenses, enhance opportunities to resolve claims fairly without protracted litigation and make the system fairer for doctors and patients alike. All parts of the health care system – lawyers, doctors, insurers and patients have a responsibility to help make the health care system more affordable.

  We need to strongly oppose the award of punitive damages in medical liability cases except upon proof of intentional misconduct, gross negligence or reckless indifference to life. The vast majority of injuries come not from negligent doctors or hospitals, but from outmoded practices, habits, and systems that are poorly designed to protect patients from errors. The gap between best practices and typical practices is extremely wide. Closing this gap for selected chronic diseases (such as diabetes, stroke, congestive heart failure, and arthritis) would dramatically improve health outcomes and reduce costs. Electronic medical records, patient registries, and reminder systems are effective in improving the quality of care and help eliminate wasteful spending - with financial incentives.

  Conflict of Interest: None declared.

  References

  1. The Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press; 2001.

  2. World Health Organization (WHO). World alliance for patient safety. Accessed on 17th March 2005: http://www.who.int/patientsafety/en/.

  3. Weissman, J.S., Annas, C.L., Epstein, A.M., et al; Error reporting and disclosure systems. JAMA 2005: 293 (11) 16.

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  Conflict of Interest:
  None declared.

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• Published on: 8 February 2005

  Not all error-prone doctors belong in Dante's Inferno!

  • Daniel K Sokol, Doctoral candidate

  Dear Editor,

  I enjoyed reading Berlinger and Wu’s article on the disclosure of medical errors. I can only agree with the authors that learning how to disclose errors and to apologise should be taught - and indeed encouraged - to doctors, even at the medical school stage. Nevertheless, I did feel uncomfortable in various places in the paper. This letter is an attempt to unearth the reasons for the discomfort....

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  Dear Editor,

  I enjoyed reading Berlinger and Wu’s article on the disclosure of medical errors. I can only agree with the authors that learning how to disclose errors and to apologise should be taught - and indeed encouraged - to doctors, even at the medical school stage. Nevertheless, I did feel uncomfortable in various places in the paper. This letter is an attempt to unearth the reasons for the discomfort.

  1. The authors provide little empirical support for their claims. Their methodology appears rather vague: ‘Our reflections are supplemented by observations from clinicians and educators, in the literature and through informal conversations’. What type – and how many – observations and informal conversations? With whom, exactly? I feel the validity of some of their claims would have been greatly enhanced by empirical work.

  2. The use of primarily religious words such as ‘forgiveness’, ‘self- forgiveness’, ‘confession’ and ‘repentance’ is, in my view, inappropriate. Such loaded language does nothing to encourage (secular) physicians to disclose their medical mistakes. How can this type of language, so focused on wrongdoing (and sin!), be reconciled with the authors’ belief that doctors should not be blamed for their mistakes?

  3. The authors write ‘When a physician refuses to tell an injured patient what really happened, the patient may literally not be able to forgive this physician, and may not be able to detach and move on from a distressing event’. Indeed, this may be true in some cases, but what if the patient never finds out? I suspect that most cases of medical error are never discovered, although I have no hard evidence to show this. On reflection, one can envisage a situation where admitting a mistake would prevent a patient from moving on.

  What if it’s almost certain that the patient will NEVER find out? Consider this scenario which I have used in my own research on truth- telling and deception in medicine:

  The doctor, by mistake, gives a wrong and probably lethal dose of medication to an 80-year-old patient suffering from very high blood pressure. Instead of giving the proper dose of 100 milligrams, the doctor misread the vial and gave 1000 milligrams. The patient appears lucid, though clearly very unwell, and asks the doctor if the reaction is normal. The doctor knows that it’s likely to be a matter of minutes before the patient loses consciousness and dies.

  In this case (which is admittedly extreme), there may be good reasons not to disclose the error and, indeed, there may also be good reasons for the disclosure. I certainly do not think it’s an easy decision (and neither do the respondents in my research!). So, arguably, there may be times when disclosing a medical error is not appropriate. The authors do not discuss such a possibility, although I suspect limitations of space were responsible for this omission.

  Also, one could argue that blindly disclosing all medical errors, however trivial, would paradoxically reduce patient trust in the doctor and in the medical profession generally. For more on the relationship between truth and trust, see Hall M, Dugan E, Zheng B, Mishra A. Trust in physicians and medical institutions: what is it, can it be measured and does it matter? The Milbank Quarterly 2001;79(4):613-639. For a more basic account of the importance of truth in the doctor-patient relationship, see Sokol D, Bergson G. Medical Ethics and Law: Surviving on the Wards and Passing Exams. London: Trauma Publishing, 2005, chapter 3.

  4. Seeing the situation ‘from the perspective of the sufferer’ is a useful exercise as it forces the agent to adopt a more impartial standpoint. Nevertheless, the variation in personal values and beliefs makes this approach fallible. Knowing what YOU would want does not, of course, tell you what that particular patient would want. I would be rather worried if my physician mechanically used the Golden Rule to make clinical decisions! My trust does have limits! But, yes, it is valuable if used in conjunction with other tools of moral reasoning. Furthermore, as the authors point out, taking the perspective of the patient’s cultural expectations may be incompatible with the application of the Golden Rule, or at least may provide the doctor with a reason not to put himself in the patient’s shoes!

  At one point in the article, the authors write that ‘physicians should take responsibility for their own errors by personally disclosing and apologising for them’. What if a patient comes from a culture where doctors do not disclose medical errors? What should the doctor who desires to ‘pay attention to a patient’s cultural expectations’ do in such a case?

  I am inclined to think that the issue of disclosure of medical errors is more complex than Berlinger and Wu make out. Perhaps this should have been made a little clearer.

  As I said earlier, I very much enjoyed their article. Thank you.

  Daniel

  Daniel K. Sokol Medical Ethics Unit Imperial College Faculty of Medicine St Dunstan's Road London W6 8RP United Kingdom E-mail: daniel.sokol@talk21.com Website: www.medicalethicist.net

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  Conflict of Interest:
  None declared.

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