When Rahul Shah, MD, then a pediatric otolaryngologist at Children’s Hospital in Boston, and several colleagues first undertook a survey of otolaryngologists’ reactions to adverse events in 2004, they provided a blank form for respondents to write about what had happened. In the more than 200 responses they received, Dr. Shah and his colleagues read an outpouring of emotion.
“It was cathartic for everyone who responded, like they had wanted to tell someone before but couldn’t,” said Dr. Shah, now on the pediatric otolaryngology faculty at Children’s National Medical Center in Washington, D.C. “They’d write things like, ‘This has been bugging me for years.’ They wanted to discuss the aftermath of adverse events in a peer fashion with colleagues but felt uncomfortable talking about these things with someone who knew them. We were nobody to them, so they could tell us.”
For years, adverse events in medicine resulted in a response similar to the one applied to gays in the military: “Don’t ask, don’t tell.” “The old attitude was that you couldn’t tell the patient anything, or they’d sue you,” said Brian Nussenbaum, MD, professor of otolaryngology and patient safety officer for the otolaryngology department at Washington University in St. Louis. “It placed an element of distrust between physicians and the public.”
And it’s not just the patient who suffers after an adverse event. Clinicians who have experienced a serious patient safety incident face their own demons. “It’s very common for clinicians to experience emotional distress following significant adverse events and errors. That distress has significant consequences, ranging from losing sleep and lack of confidence in your own clinical skills to difficulty focusing on meeting the needs of your patients,” said Tom Gallagher, MD, an associate professor of medicine at the University of Washington in Seattle and a nationally known expert on medical errors and disclosure.
In recent years, led by vanguard institutions like the University of Michigan and the University of Illinois at Chicago, this attitude has begun to change. Research has shown that patients and families who experience an adverse event are, in fact, much less likely to sue a doctor or a hospital that admits fault in an incident and expresses a sincere apology. At the University of Michigan, for example, the medical error disclosure program brought litigation costs down to $1 million from $3 million between 2001 and 2005, and annual claims and lawsuits were reduced by more than half, from 261 to 114, according to a report in the Journal of Health & Life Sciences Law (2010;2(2):125-1569). And as Timothy McDonald, chief safety officer at the University of Illinois, told the Wall Street Journal on Aug. 25, when the university introduced a similar program in 2004, lawsuits dropped by 40 percent over the next five years, even as the number of procedures went up.
—Jo Shapiro, MD
Washington University’s primary hospital, Barnes-Jewish, is now in the process of establishing a disclosure coaching program that will be accessible through a hotline number.
“We plan to have a group of disclosure coaches, primarily physicians, as resources for the faculty,” Dr. Nussenbaum said. “They will be trained dually in helping the physician get through the disclosure process with the patient and family and, at the same time, helping the doctor get through the event.”
Many experts in disclosure and adverse events agree that one of the most progressive programs for helping not only patients and institutions, but also individual clinicians, deal with the aftermath of such incidents is the one founded by Jo Shapiro, MD, chief of the division of otolaryngology at Brigham and Women’s Hospital in Boston. Launched in the fall of 2008, the Center for Professionalism and Peer Support comprises several different components, such as disclosure coaching and a defendant support program for clinicians named in a lawsuit. But perhaps its most innovative element is a cadre of trained peer supporters who actively reach out to any physician involved in an adverse event.
“The peer counselors provide support, ask how the person is feeling, and get them referred to more professional help if needed,” Dr. Shapiro said. “Physicians tend to feel that they should handle things themselves, so we don’t wait for them to call us—because they won’t. We call them. People have told us that they find it really helpful—even if they don’t necessarily want to sit down and talk, just knowing that the institution cares enough to reach out to them is important.”
The peer-to-peer outreach aspect of Dr. Shapiro’s program is particularly helpful, according to Dr. Gallagher. “A more common approach is for organizations to use pre-existing support resources for helping employees with other problems, like employee assistance programs,” he said. “That sounds good in theory, but in practice, it doesn’t work out so well, in part because many of those efforts rely on the clinician to be the one to initiate the contact.”
But even most academic medical centers—to say nothing of smaller local hospitals and practices—don’t have the resources to establish a peer support program. According to Dr. Nussenbaum, of the 108 or so academic otolaryngology programs in the country, probably fewer than half have a specific staff person dedicated to dealing with patient safety activities and disclosure. “Overall, our specialty is probably behind in terms of dealing with disclosure and adverse events,” he said. “It’s very little discussed at our meetings, and most of the exposure I’ve had to this subject is not through our department [but] through other avenues at our hospital.”
So how can individual doctors and otolaryngology departments or practices make sure they’re offering, and getting, the support they need after an adverse event?
Dr. Shah offered the following tips:
- Be overly pessimistic every day, although that may seem counterintuitive in a profession focused on optimism. “Be preoccupied with failure,” Dr. Shah said. “I’m a high-volume surgeon doing 700 surgeries every year, and before each one, I think ‘What could go wrong?’”
- Realize that errors do occur. “Start with the premise that ‘yes, I can understand how this can happen, let me see how I can mitigate it in my practice,’” Dr. Shah said.
- Have a clearly stated position on disclosure and apology. Individual physicians should know those positions and should call their hospital’s risk manager or legal counselor immediately after an adverse event.
- Have a regular peer-to-peer discussion of adverse events within the practice. If you don’t have a system, members can always call the American Academy of Otolaryngology-Head and Neck Surgery, according to Dr. Shah, who is co-chair of the Academy’s patient safety committee. “We’re always available to provide guidance,” he said.
Another resource is the disclosure chapter of the University of Michigan’s “Patient Safety Toolkit,” which includes step-by-step guidance on how and when to disclose errors (med.umich.edu/patientsafetytoolkit/disclosure.htm). The “Sorry Works” coalition (sorryworks.net) also offers disclosure booklets, tip cards, guidelines and PowerPoint presentations.
According to Dr. Shapiro, the ability to talk about medical errors is vital to the practice of good medicine. “One of the biggest morale busters at most institutions is the sense people have of not being fully valued or respected,” she said. “Support after an adverse event is a key part of valuing your clinicians. The more people feel trusted, respected and valued, the better work they can do taking care of patients.”