When the team of otolaryngologists from Children’s Hospital in Boston, including Drs. David Roberson and Rahul Shah, among others, investigated the classification of errors and physician responses to errors as it is germane to otolaryngology, they provided a great service to their fellow specialists. As the team emphasized, and was mentioned in Part 1 of this two-part series (see ENToday, November 2006), when it comes to provider-related errors, otolaryngology is different from other specialties only in some ways.1-6 That’s why patient safety programs need to be driven by practitioners at the sharp end of the system, at the point of care, not by a [general] patient safety committee, said David Eibling, MD, a physician in the Veterans Affairs (VA) system and a professor of otolaryngology-head and neck surgery at the University of Pittsburgh, because they are not able to see the unique problems of each individual specialty, and moreover, you don’t know where your own problems are unless you count them.
Before the publication of To Err is Human,7 the now famous report of the Institute of Medicine that started the patient safety ball rolling at turbo speed, the most frequent subject of patient safety publications was medical malpractice. Since its release in 2000, the most frequently addressed topic has been organizational culture, and growing data substantiate that the way in which communication is handled within that culture is a vital factor in litigation and patient satisfaction.5
Pitfalls and Land Mines
Are there any particular areas where otolaryngologists are more at risk for errors than other physicians? For any physician, medical knowledge and technical skill, or even patient-doctor relationship skills, are not the biggest areas for risk, said Nancy Elder, MD, Associate Professor of Family Medicine at the University of Cincinnati, who has studied extensively the topic of errors in medicine. Sometimes the risks lie not so much with the physician himself or herself; it’s the communication before and after the exam or operation, or the providers’ office processes and systems. The patient doesn’t have to just communicate with the physician, Dr. Elder said. The patient also has to communicate with whoever answers the telephone, the front desk, the nurse-and a lot of errors are happening in these areas that physicians are not even aware of.
For instance, she said, patients may not be getting prescription refills because there is laxity and inattention to returning the patients’ phone calls. Or patients are often told, If you don’t hear from me about your lab test, it means everything is all right. Nobody should suggest that that is okay, said Dr. Elder, who tells patients never to allow anyone to tell you that.8, 9 Aside from the interactions in examination rooms and the operating theater, she said, all the people that work around [doctors] need to be functional, and physicians need to take an active role in that.
The Emotional Realm
In a retrospective anonymous survey sent to 2,500 otolaryngologists, all members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), Rahul Shah, MD, and his colleagues at Children’s Hospital, Boston, inquired about errors that had been made in the previous six months.3, 4 Two particular aspects of the data distinguished themselves beyond the scope of the original study: respondents’ emotional responses and their corrective actions.1 Although unasked, 22 (10%) of respondents reported having experienced emotions including regret, embarrassment, guilt, anxiety, loss of temper, and irritation. The authors remarked that although surgeons are well trained in how to handle errors and adverse events in terms of their complications, they are not as used to dealing with their own emotions and those of their patients.
How a provider responds in these types of circumstances is important for a variety of reasons. First, said Dr. Eibling, accepting personal responsibility-be it for an error you were responsible for or an error that was facilitated by the design of the system-enables you to apologize authentically to the patient and tell them that you’re going to do whatever possible to ensure that it won’t happen to another patient. In addition, he said, it’s my belief that acceptance of responsibility for errors facilitated by the system’s defects will increase the practitioner’s ownership, and their interest and enthusiasm to change the system.
After the Error
After the systems have broken down or an incident has occurred, communication must be quick, careful, and authentic. In that way, said Dr. Shah, now with the Division of Otolaryngology at Children’s National Medical Center in Washington, DC, we are all in the same boat. What a family doctor talks about to patients is similar to the way a surgeon would speak, the only difference being that our mistakes could happen in the operating room.
Dr. Eibling, who lectures on medical errors and patient safety issues to medical staffs as well as residents in otolaryngology and other specialties, agrees. Although he uses otolaryngology-specific examples in his presentations, the concepts are not unique to otolaryngology. I think that the fundamental precepts defined in the book by Michael Woods, Healing Words: The Power of Apology in Medicine,10 remain the same, he said.
Disclosure and apology in medicine has garnered a great deal of attention in the past few years11-13 and the wording used in those interactions between providers and patients is especially important. An organization called Sorry Works!, a coalition of physicians, lawyers, hospitals and researchers, is making especially prominent headway in this sensitive area and is making an impact across specialties, settings, political bodies, and professions.
Two Kinds of Disclosure
As is apparent to anyone working in medicine today, improving the systems in which practitioners work is now a huge focus in both the scientific and lay literature.2,4,5,7,14-18 An additional focus has been the disclosure of errors and how disclosure differs from apology.
One of the most important distinctions after an error has been recognized is whether the provider reveals to the patient that there was a complication versus admitting and taking responsibility for having made a mistake. In a study conducted in 2005 by Chan et al. using standardized patients, surgeons were rated highest on their ability to explain the medical facts about errors, but they used the word error or mistake in only 57% of conversations.19 In 27% of cases, surgeons used the words complication or problem.
Dr. Eibling pointed out that the concept is nicely demonstrated by the work of Wu et al.20 as well as in the training video Wu and colleagues produced at the Johns Hopkins Bloomberg School of Public Health, titled Removing Insult from Injury: Disclosing Adverse Events. Three scenarios from the video are available for free download from the Johns Hopkins Web site (see box).
The illustrative scenarios clarify that there is a big difference between saying something happened and something happened and it was my fault. That difference matters and is a critical factor that is often overlooked, said Dr. Eibling.
Throughout organized medicine regulations requiring disclosure are now being implemented. But disclosure is an institutional responsibility, said Dr. Eibling. It is not the same as apology. Dr. Eibling, who performs all his surgery within the VA, appreciates the policy that the VA published a year ago, which differentiates institutional disclosure (here’s what happened and we are going to do whatever we can do to remedy this for you, including assuming some of the cost of your care) from informal disclosure (disclosure by the provider combined with an apology).21 The difficulty is not in saying something bad happened, said Dr. Eibling, but in saying something bad happened, it’s my fault, and I feel terrible about it.
That wording matters to the patient and the provider.22 Until there has been an apology to and forgiveness from the patient, the patient and family are unlikely to experience closure. And data substantiate that if a patient can reach forgiveness and compassion for the humanity of making an unintended error, he or she is less likely to pursue litigation. In addition, the physician can also find closure.1 Apology is key in moving beyond the error into a continued physician-patient relationship, said Dr. Eibling, because unless the patient and physician both can find closure, the provider may well be a ‘second victim.’23
Dr. Eibling advocates using role play to practice apologizing to patients because the opportunity to disclose and apologize is never one where you plan ahead; it just happens to you, he said, and practicing saying you’re sorry makes it easier when you really need to do it.
For the very reason that the needs for disclosure and apology come up unexpectedly, said Dr. Shah, there are certain imperative aspects of those requisite conversations. Having been able to watch senior physicians disclose problems that have occurred has been a boon to the development of his own techniques and those he now teaches his residents and students. What I notice is that these [conversations] are usually [conducted] immediately after the incident has occurred, he said, and not in the patient’s room but in a separate location that is quiet and private. Other aspects of authentic and respectful apology include sitting down, appearing non-rushed, temporarily ignoring your pager or cell phone if possible, paying attention to body language (avoiding crossed arms or being turned away from the patient; using touch, if appropriate) and letting the patient know that you are there for them at that moment. The senior, classier physicians, he said, whom trainees admire and attempt to emulate don’t look harried or distressed and thus appear to the patient and family as experienced, calm and confident, offering explanations in a very matter-of-fact way.
Systems Are People-Based; People Can Change Them
In his lectures on the subject of medical errors, Dr. Eibling reminds his audiences that the systems in which we work were in fact all designed by people, and since they were built by people, people can change them. Also, he pointed out, it is essential to share creative solutions to systemic problems with colleagues whether by publishing, or in formal or informal discussions. Not only do we have a responsibility to identify and measure problems, if they are measurable, said Dr. Eibling, but we have a responsibility to fix them and then report the fixes so others can benefit.
Putting Advice into Practice
David Eibling, MD, who, in addition to his clinical duties, is the vice chair for education in the department of otolaryngology at the University of Pittsburgh Medical Center, told ENToday about an incident that had occurred only a few days before he was interviewed for this article. He believes it illustrates the need for authenticity in communications and the natural path from disclosure and apology to systems improvement.
I apologized to a patient and his family the day before yesterday because I forgot to do the tracheal esophageal (TE) puncture that I’d told the patient I was going to perform. The pharyngeal closure was difficult and at the completion of the procedure, I realized I had forgotten to place the TE puncture. I did not tell the patient and family that I had decided not to do it because the closure was difficult, because that was not true. I told them, I was focused on the fact that the closure was difficult and because my brain was working with that, I just plain forgot and I’m very sorry because it now means that you are going to need another operation at some time in the future to place this tracheal esophageal puncture. To me this represents the fundamental essence, if you will, of apology. With the patient and family, I went over the 4 R’s: recognition [that there was an error], regret, responsibility, and remedy. I also pointed out to them that I have now changed my system in the OR: every time I request the NG tube, which you use at the same time of the procedure, I will also be handed the instrument and catheter to perform a TE puncture.
Resources on the Web
Doctors, insurers, patients, lawyers, hospital administrators, and researchers joining together to provide a ‘middle ground’ solution to the medical malpractice crisis
Johns Hopkins scenarios
Removing Insult from Injury: Disclosing Adverse Events
- Lander LI, Connor JA, Shah RK, et al. Otolaryngologists’ responses to errors and adverse events. Laryngoscope 2006;116:1114-20.
- Roberson DW, Kentala E, Healy GB. Quality and safety in a complex world: why systems science matters to otolaryngologists. Laryngoscope 2004;114:1810-4.
- Shah RK, Kentala E, Healy GB, et al. Classification and consequences of errors in otolaryngology. Laryngoscope 2004;114:1322-35.
- Shah RK, Roberson DW, Healy GB. Errors and adverse events in otolaryngology. Curr Opin Otolaryngol Head Neck Surg 2006;14:164-9.
- Stelfox HT, Palmisani S, Scurlock C, et al. The To Err is Human report and the patient safety literature. Qual Saf Health Care 2006;15:174-8.
- Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors: a review of the literature. Arch Intern Med 2004;164:1690-7.
- Kohn LT, Corrigan JM, Donaldson MS, Institute of Medicine Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
- Elder NC, Dovey SM. Classification of medical errors and preventable adverse events in primary care: a synthesis of the literature. J Fam Pract 2002;51:927-32.
- Elder NC, Jacobson CJ, Zink T, et al. How experiencing preventable medical problems changed patients’ interactions with primary health care. Ann Fam Med 2005;3:537-44.
- Woods MS, Star JI. Healing Words: The Power of Apology in Medicine. Santa Fe, NM: Doctors in Touch; 2004.
- Duclos CW, Eichler M, Taylor L, et al. Patient perspectives of patient-provider communication after adverse events. Int J Qual Health Care 2005;17:479-86.
- Hoy EW. Disclosing medical errors to patients. Ear Nose Throat J 2006;85:410.
- Lazare A. Apology in medical practice: an emerging clinical skill. JAMA 2006;296:1401-4.
- Leape LL. Editorial. Physician self-examination. Int J Qual Health Care 1998;10:289-90.
- Leape LL. Errors are not diseases: they are symptoms of diseases. Laryngoscope 2004;114:1320-1.
- Leape LL, Rogers G, Hanna D, et al. Developing and implementing new safe practices: voluntary adoption through statewide collaboratives. Qual Saf Health Care 2006;15:289-95.
- Longo DR, Hewett JE, Ge B, et al. The long road to patient safety: a status report on patient safety systems. JAMA 2005;294:2858-65.
- Lubell J, DoBias M. Medication errors persist: IOM. Report highlights steps to reduce severity, frequency. Mod Healthc 2006;36:10.
- Chan DK, Gallagher TH, Reznick R, et al. How surgeons disclose medical errors to patients: a study using standardized patients. Surgery 2005;138:851-8.
- Wu AW. Handling hospital errors: is disclosure the best defense? 1999;131:970-2.
- Cantor MD, Barach P, Derse A, et al. Disclosing adverse events to patients. Jt Comm J Qual Patient Saf 2005;31:5-12.
- Gallagher TH, Garbutt JM, Waterman AD, et al. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Int Med 2006;166:1585-93.
- Wu AW. Medical error: the second victim. BMJ 2000;320:726-7.
©2006 The Triological Society