The messages transmitted implicitly on the job, through everyday vocabulary, practices, and habits, all of which have powerful effects on individual attitudes and practices. This phenomenon is particularly relevant to medicine, where longstanding, and often rigid, traditions about hierarchy allow actions of senior physicians—positive and negative—to strongly influence student behavior.43
The Shame That Divides Us
The book Wall of Silence describes what seems like countless, horrific stories of hospital errors. In one chapter alone, they describe ten patient safety cases, which are summarized below.
Many Faces of Healthcare-Induced Harm
World War II veteran: Okie was a strong and energetic husband and father to four children, but he died because a nurse failed to attend to a written order stating not to reinsert the tube that passed from his nose to his stomach if it came out.
White House executive: Daniel underwent what turned out to be an unnecessary surgery that caused cranial nerve damage, leaving him debilitated and unemployed in the prime of his life.
Emmy Award–winning TV news anchor: Mary underwent cosmetic surgery to maintain her TV ratings, but she was left with pain that is so debilitating she is unable to work or socialize normally.
Wise beyond her years: Eight-year-old Elizabeth is permanently paralyzed from the waist down because doctors didn’t listen when she told them her cancer was back. As she lay suffering, the sensitive young girl wanted to know why the doctors didn’t believe her.
Financial manager: Susan suffered a botched laparoscopic procedure, required multiple follow-up surgeries, $150,000 in medical bills that weren’t covered by insurance, and lifelong pain and difficulty going to the bathroom.
Mother and real estate agent: Marion was an optimistic and cheerful woman who died while waiting for her first cancer treatment because the staff oversedated her with opiate pain medication that she didn’t need or request.
Former Air Force intelligence officer: Diana was in her thirties and in good shape. She worked out regularly despite ongoing hip pain. After much debate, she elected to undergo a surgical procedure to correct the situation. The surgery went well, but Diana was left unattended for hours and unable to get any medical attention. Outraged by poor postoperative care, she transferred to another hospital. While still weak and “fuzzy” from the surgery and drugs, she fell. Her pain worsened, but she was written off as “hypersensitive” and her pain medications were increased. It turns out that her new joint had been dislocated. Because the dislocated hip was overlooked for weeks, Diana needed several more surgeries, which were also error-ridden experiences, and it was years before all the damage from the initial postoperative failures were resolved.
Model high school student: In so many ways, fifteen-year-old Lewis was every parent’s dream child. He was admitted for surgery to undergo a new procedure for fixing a relatively common sunken chest condition called pectus excavatum. The new surgical procedure was a success, but Lewis died because he developed a bleeding ulcer from a powerful painkiller and the hospital nurses repeatedly disregarded his complaints and alarming symptoms.
Grandmother with a will to live: Madeline lost twenty-five pounds and deteriorated rapidly from severe pain due to staff failure to address her complaints—described like a knife in her side—or to notice that an X-ray clearly showed that a four-inch pin used to hold broken bones in place had come loose and traveled into surrounding hip tissue. She needed additional surgery, and it took three years for her to regain her strength.
Star quarterback and college student: Justin was a healthy and tough young man, but he died within two days of visiting a hospital where a serious infection was overlooked in spite of signs that septic shock was setting in.
What do these seemingly diverse patient safety stories have in common? Nobody who cared for these patients ever apologized for the mistakes that occurred—except one of the many physicians who treated all the patients harmed. Imagine you were Elizabeth’s mother and that as she lay there learning to cope with a life of paralysis, her request to meet with her doctors to ask, “Why didn’t you believe me?” was repeatedly denied. If that isn’t a case of unnecessary pain being inflicted on a traumatized girl and her mother, I don’t know what is. And yet, here’s what the young girl said to her distraught mother, “I forgive you, Mom, but you have to forgive yourself.”44
Time and again, the victims profiled in Wall of Silence expressed the sentiment that they could live with the mistakes that were made, but not with the fact that nobody would apologize for them. As Okie’s wife said, “We need hospitals to speak up and tell the family that a mistake was made and consult with them to explain what happened. This would have meant a great deal to me and helped in the healing process.”45 And here’s how a woman whose father died because his blood thinner was refilled incorrectly explained the need for an apology.
Adding Insult to Injury
Just think if my neighbor is driving down the road in front of my house, and I’m looking out my window and see him hit my dog that was running across the street. If he gets out of his car and picks up my dog and brings him up to the house, truly sad and upset for what happened, how can I be mad at him? I would try to make him feel not so bad for something he certainly didn’t intend to do. But if he kept on driving and later comes up to the house, lies to me, and says he didn’t do it, and yet I saw him do it, you can imagine how mad that would make me feel.46
It’s Not All about Physicians
What is also disconcerting about current disclosure practices is that nurses, pharmacists, respiratory therapists, physical therapists, and all other healthcare workers have been largely omitted from the discussion about how to handle the aftermath of medical errors, even when they have been directly involved in them. Given nurses’ central role in the care of patients, this is a particularly significant oversight. The American Association of Colleges of Nursing describes the role of nursing this way:
Though often working collaboratively, nursing does not “assist” medicine or other fields. Nursing operates independent of, not auxiliary to, medicine and other disciplines. Nurses’ roles range from direct patient care and case management to establishing nursing practice standards, developing quality assurance procedures, and directing complex nursing care systems.47
And yet, when it comes to disclosure, typically nurses have been treated as a dyad wherein the physician and/or hospital can plan for disclosure and communicate with patients without their input or involvement. Not surprisingly, some nurses report being left in ethically compromising positions, sometimes feeling the need to disclose errors to patients without physician awareness.48 Like physicians, nurses (and all licensed providers) can be sued.49
Excluding any member of the healthcare team, preventing them from honestly and appropriately disclosing errors, or confronting them with undue criticism or punishment can exacerbate their stress. High stress leads to underperformance and burnout that, in turn, increases the likelihood the providers will become more error-prone.
Openness and Healing
Hiding mistakes not only adds insult to injury for patients and families, it also complicates and compromises the healing and learning of providers. Again, in the words of Dr. Wu:
Guilt, Confession, and Recovery
It has been suggested that the only way to face the guilt after a serious error is through confession, restitution, and absolution. But confession is discouraged, passively by the lack of appropriate forums for discussion, and sometimes actively by risk managers and hospital lawyers. . . .
In the absence of mechanisms for healing, physicians find dysfunctional ways to protect themselves . . . Distress escalates in the face of a malpractice suit. In the long run, some physicians are deeply wounded, lose their nerve, burn out, or seek solace in alcohol or drugs.50
Fortunately for all of us, in the wake of Josie King’s death
in 2001, Johns Hopkins took the bold step of becoming the first hospital to openly disclose what went wrong with the family, invited the family to be part of the investigation, and shared the lessons learned with the hospital community and broader public. Although Sorrel King and her husband, Tony, elected not to participate in the investigation, the hospital kept them abreast of everything that was learned. A hospital executive gave Sorrel his direct phone number with an invitation to call at any time, and he set up a weekly conference call to share with her the progress of the investigation.51
Such openness is critical because the investigation of a patient safety event can take weeks or months to complete and asking patients to wait until the process is over for any feedback is inhumane. Excluding patients from knowing what is going on behind the scenes can worsen their fears and doubts, engendering a greater sense of distrust and anger. In fact, nearly half of malpractice claims are filed because patients and families had become suspicious that providers were covering up mistakes or because they wanted information.52
Wu and others from Johns Hopkins now advise healthcare institutions and train providers to treat disclosure as part of the ongoing dialogue with the patient and/or the patient’s family. They believe that keeping patients and families informed about everything as it is being learned is simply a matter of providing decent, quality care. It is also consistent with the modern healthcare notion of “nothing about me without me.” As full disclosure champions, Wu and his colleagues speak about the “golden hour” for sharing information with patients. They recognize that failure to be immediately forthcoming can break trust when disclosure finally occurs, creating the worrisome sense of, “You mean, you knew this all along and weren’t telling me?”53 Although there is a long way to go before full disclosure becomes a routine practice, there is evidence that people have been listening.
In 2000, only 29 percent of first-year medical residents indicated that they would disclose a medical error to patients; by 2009, the number was up to 55 percent.54 The number of hospitals that have implemented full-disclosure policies also continues to rise. A critical lesson that has been learned from trailblazing institutions such as Johns Hopkins, the VA Health Care System in Louisville, Kentucky, the Michigan Health System, and Ascension Health as well as from efforts to replicate their efforts is this: the success of full-disclosure policies depends on the organizational culture in which they are embedded.55 And the great news is that with sufficient preparation, internal promotion, and professional training, full-disclosure programs can work incredibly well.56
Ascension Health—a large healthcare system with over seventy hospitals and hundreds of outpatient facilities in at least half the United States—provides one of the most recent and compelling stories of the power of a strategically implemented full-disclosure program. In 2007, Ascension implemented a full-disclosure policy across its system with the goal of 100 percent adoption, but it turned out that only about 10 percent of hospital teams and providers adhered to the policy. Culture trumped policy, just as it did with the Rhode Island hospital described in chapter 4. So, in 2011, Ascension transformed its policy into a manageable program—a program that is consistent with the elements that have become recognized as essential to effective disclosure.57
Leaders selected a handful of labor and delivery sites to develop, implement, and evaluate the process. First, program leaders created a single and easily understood protocol out of the existing protocols that varied in length and clarity. They also held meetings to introduce the program before expecting compliance, trained a response team at each hospital to facilitate and be accountable for the process, and provided each hospital with disclosure coaches who had been prepared to assist providers and administrators when events occurred. Ascension also collaborated with a medical liability insurance company to develop and provide physicians premium credit for completing error analysis and disclosure training. Their strategic efforts to translate policy into action paid off.
Twelve months into the program, 43 percent of participants supported full disclosure; after twenty-seven months, 77 percent fully supported it. What’s more, by about two years into the program, participant buy-in was accompanied by a 221 percent increase in the rate of documented disclosures across all participating facilities.58
Ascension used scripts to train providers on what to say when discussing adverse outcomes with patients in a manner that would attend to all the elements that Wu and colleagues have identified as essential to effective disclosure.59 As the table below suggests, the concept of full disclosure is intended to meet the needs of patients and families, but each element also confers potential benefits to healthcare providers.
Table 7.2.
Key Elements of Full Disclosure
Key Elements
What Patients Desire
Potential Benefit to Providers
Explanation
Timely accounting of what went wrong and why it happened
Maintain patient’s trust, improve safety knowledge
Responsibility
Appropriate ownership by provider and/or hospital for what went wrong
Reduce likelihood of a lawsuit
Apology
Sincere apology with expression of provider’s distress and sympathy for patient or family
Experience emotional relief, lessen likelihood of second victim phenomenon
Prevention
Promise effort will be made to learn from the event and prevent similar recurrences
Strengthen and reinforce a culture of safety
Compensation
Nonadversarial process to ensure financial reparations
Hasten resolution and healing, decrease litigation and settlement time and costs
The Ascension program relied on highly scripted language that employees practiced in advance of disclosing information about adverse outcomes to patients, which the staff reported was very helpful. These scripts represent not only what providers need to learn to say, they are also what patients need to hear. In addition to modeling how to translate hospital policy into action, the Ascension story can serve as a blueprint of how a community coalition might implement changes it prioritizes.
Disclosing Potential Error60
We are sorry that this event occurred and want you to know it is being reviewed carefully to determine the cause. As soon as this assessment is completed, we will meet with you to let you know the findings.61
Disclosing an Error-Free Adverse Event
We are very sorry that this event has occurred. We have completed the review and the event was not preventable for the following reasons.62
Disclosing Healthcare-Induced Harm
We are very sorry that our actions led to this very disappointing outcome. We would like to explain what happened and what changes we have made so this won’t happen again. We will work with you to try to make you whole and earn back your trust.63
As the public becomes more aware of the nature of the patient safety crisis, we cannot afford to delay the educational reforms that are necessary to support full disclosure or to neglect the needs of providers who are honest with their patients. Fortunately, over thirty states have laws in place to protect physician apologies from liability, recognizing that apologizing does not necessarily imply guilt.64 In time, the public may gain appreciation for the fact that sometimes patients deserve to be compensated without meaning that the provider deserves to be punished.
The Economics of Honesty
Being honest and transparent with patients about medical errors is not only the right thing to do, it also pays dividends. In 2001, the University of Michigan Health System began fully disclosing medical errors to patients and families and offering them compensation for such errors. An analysis of claims data for six years before and six years after the system began fully disclosing medical errors provided substantial evidence of the financial benefit of being honest and transparent with patients and their attorneys. After the disclosure program began, the average rate of new claims fell by 36 percent. The average monthly rate of lawsuits also decreased by 65 percent. The median time from claim reporting to resolution was shortened by 30 percent. The healthcare system’s average monthly cost rate for total liability, patient compensation, and noncompensation-related legal costs all decreased by about 40 percent.65
In 2009, the Agency for Healthcare Research and Quality dispersed $25 million to support demonstration projects related to full disclosure and medical liability reform, including the Ascension program.66 These projects suggest there is still much to be learned about the best ways to connect full-disclosure communications with compensation mechanisms and models. It is possible that disclosing errors and offering compensation before a malpractice claim is filed may lead to an increase in the number of claims filed.67 Even so, this practice could still be beneficial to patients without having a negative impact on the bottom line of institutions or insurance providers because about 85 percent do not merit compensation68 and the majority of medical malpractice dollars are spent on legal fees (not on victim compensation or punitive damages).69 Furthermore, the process is more conducive to learning and healing from adverse events and to preventing their recurrence.
In the words of a public health professional, an attorney, and a physician:
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