“Initially the concept was somewhat foreign,” said Edward Damrose, MD, an otolaryngologist at Stanford University Medical Center who will soon be chief of staff at Stanford Hospital. “Traditionally, doctors were taught: ‘Say nothing, admit nothing, and let the lawyers talk.’ Never say you’re sorry—that’s tantamount to admitting guilt.”
Explore this issue:July 2015
Stanford physicians quickly warmed to the idea, however. Dr. Damrose called it a breath of fresh air. “When something bad happens, doctors do feel sorry, even if they’re not at fault. It can be cathartic and liberating to say you’re sorry.”
At Stanford, the primary assessment determines whether a bad outcome was unanticipated and was preventable. Dying of a terminal illness, for instance, is anticipated, while a retained foreign body is a preventable, unanticipated event, and full disclosure is indicated. “We take ownership of the error: This is what happened, it was preventable, and we’re taking measures to keep it from happening to anyone else,” Dr. Damrose said.
The state of Massachusetts passed a “Disclosure, Apology, and Offer” law in 2012, a first in legislating such conduct of healthcare organizations. The law calls for a six-month “cooling off” period, during which the communication and resolution process should take place. After that, patients can still choose to sue healthcare providers if they want, although statements of apology will be inadmissible in court.
Many physicians and health policy researchers point to the influential 1999 Institute of Medicine report, “To Err is Human,” which documented the harms that physicians and hospitals sometimes inflict on their patients for a whole variety of reasons. The report called for greater transparency in healthcare.
Two years later, the Joint Commission on Accreditation of Healthcare Organizations established new safety standards for patients, including disclosure of unanticipated outcomes.
These two influential organizations certainly helped turn the tide of practices that encouraged doctors and their patients to become adversaries in the courtroom. But a VA Hospital in Lexington, Ky., is widely credited with being the first healthcare facility to institute a full disclosure policy.
Two huge malpractice claims in a single year—1987—spurred the Lexington VA to take action. Intending to be more proactive in risk management practices, a committee bumped up against the ethics of informing patients when they may have been unaware of an error. In a 1999 paper describing the disclosure policy and its impact, then chief of staff Steve Kraman, MD, wrote:
The committee members decided that in such cases, the facility had a duty to remain in the role of caregiver and notify the patient of the committee’s findings. This practice continues to be followed because administration and staff believe that it is the right thing to do and because it has resulted in unanticipated financial benefits to the medical center” (Ann Intern Med. 1999;131:963-967).