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Disclosing Medical Errors
6 Plays6 years ago
In this episode of Critical Matters, we continue the discussion of medical errors in healthcare with a specific focus on how to disclose medical errors to patients. Our guest is Dr. Nitin Puri, a practicing intensivist and medical educator at the Cooper Medical School of Rowan University and the Cooper Health System in Camden, New Jersey.
Additional Resources:
This is a CNN story on cardiothoracic fellow wrongly accused and sued for lying about a medical error: https://cnn.it/2vFEnLf
The Communication and Optimal Resolution (CANDOR) toolkit from the Agency for Healthcare Research and Quality (AHRQ). CANDOR is a process that health care institutions and providers can use to respond in a timely, thorough and fair way when medical errors occur and cause patients harm: https://bit.ly/2m9fch7
A powerful video on the topic of the disclosure of medical errors: https://bit.ly/2DaD6TD
Article Mentioned in This Episode:
Mistakes Were Made (but Not by Me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts: https://amzn.to/2NorssU
Recommended
Transcript
Introduction to the Podcast
00:00:09
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:17
Speaker
And now, your host, Dr. Sergio Zanotti.
Debra Craven's Medical Error Case
00:00:23
Speaker
In 2015, Debra Craven had surgery at Yale to remove part of her eight rib.
00:00:27
Speaker
Unfortunately, a mistake was made and the wrong rib was removed.
00:00:31
Speaker
The hospital admitted that a mistake was made during that surgery and Craven pursued a lawsuit that detailed how her seventh rib was removed instead of her eighth rib and she had to have a second surgery to remove the correct rib.
00:00:45
Speaker
But her lawsuit went on to say something that later turned out not to be true.
00:00:50
Speaker
She accused Dr. Ricardo Query by name of lying to her about the reason for the second surgery to cover up the mistake.
00:00:57
Speaker
Dr. Ricardo Queria at the time was a cardiothoracic fellow at the Yale New Haven Hospital and was part of the surgical team that intervened on Ms.
00:01:06
Speaker
Craven.
00:01:08
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Unfortunately for him, this accusation created a lot of negative press that has really made it difficult for him to pursue jobs since finishing his fellowship.
00:01:19
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In a recent turn of event, the lawyer involved with this lawsuit has regularly recanted and has stated that
00:01:25
Speaker
that the statements attributed to Dr. Query were incorrect, and a letter tried to clarify this misunderstanding.
00:01:33
Speaker
Unfortunately for Dr. Query, the two years that have gone since this lawsuit was made public have created all sorts of problems.
00:01:40
Speaker
This case, very dramatic and in the recent press, I think illustrates many of the issues related to medical errors, not only the fact that they are a cause of tremendous suffering and pain for patients, but they also can have
00:01:54
Speaker
bystander as victims or can also affect people involved in the care of these patients.
00:01:59
Speaker
But most importantly for today's discussion, I think it centers on the need for very appropriate and very effective disclosure of medical errors when they occur and to make sure that we have full disclosure and open lines of communications with our patients.
00:02:16
Speaker
Today's
Impact and Discussion on Medical Errors
00:02:17
Speaker
topic is
00:02:17
Speaker
is Disclosing Medical Errors.
00:02:19
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It's a follow-up from a previous discussion we had with our guest, who's back today, Dr. Neethan Puri, on medical errors.
00:02:26
Speaker
Dr. Puri is Program Director of Critical Care Medicine and an Associate Professor of Medicine at Cooper Medical School of Rowan University and Cooper University Healthcare.
00:02:36
Speaker
Dr. Puri is an accomplished clinician and medical educator.
00:02:39
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He's board certified in internal medicine, pulmonary disease, critical care, and neurocritical care.
00:02:44
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Dr. Puri runs a recognized fellowship program in critical care medicine,
00:02:47
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and works clinically at the Medical Surgical Intensive Care Unit at Cooper University Hospital.
00:02:53
Speaker
He was our guest on Critical Matters on a previous episode where we discussed medical errors in a very broad session.
00:02:59
Speaker
Today, we're continuing this conversation with a specific focus on the disclosure of medical errors to patients.
00:03:06
Speaker
Welcome back to the podcast, Nitin.
00:03:10
Speaker
Thank you very much, Sergio.
00:03:12
Speaker
So I think this case really illustrates a lot of the aspects or a lot of the potential perils that surround the disclosure of medical errors.
00:03:21
Speaker
We talked about in our previous podcast, Nitin, that medical errors occur.
00:03:26
Speaker
They probably occur with a frequency that's much higher than we like to admit or that is reported.
00:03:31
Speaker
But I think that one of the aspects that we didn't dive in as deeply is what's the best way or the most effective way to make sure that we disclose these medical errors the right way.
00:03:42
Speaker
Yeah, this case is fascinating.
00:03:47
Speaker
You know, one that I'm sort of not as familiar with, but
00:03:52
Speaker
It does bring up the point about medical errors is that physicians are human beings too and can be hurt significantly by mistakes they make, not only just the patients, and that we need to hold physicians accountable for medical errors, but we also need to protect them from draconian penalties.
00:04:18
Speaker
Part of the
Strategies for Error Disclosure
00:04:19
Speaker
reason there's the wall of silence
00:04:21
Speaker
in disclosing medical errors is that physicians have fear of the consequences of being honest with patients and families.
00:04:33
Speaker
And, you know, the families or the people who were hurt, they want us to be honest with them.
00:04:41
Speaker
and they don't want to be hurt twice, right?
00:04:44
Speaker
You know, the first time there's a medical error committed and then our response is to keep quiet and then, you know, there's perhaps litigation that drags out for two to five years.
00:04:56
Speaker
It creates a hostile and negative experience the whole way around.
00:05:02
Speaker
And so creating a process to deal with medical errors
00:05:09
Speaker
is an ideal scenario, and some institutions have done a very good job with it and made a significant difference in patient lives and physician lives.
00:05:22
Speaker
So I think that a good starting point for our discussion would be capitalizing or maybe emphasizing what do you think, Nitin, are common or essential components of a good medical error disclosure to a patient?
00:05:40
Speaker
I believe an organized process is important.
00:05:46
Speaker
After a medical error occurs, the first thing that a physician will normally feel is panic because they are, you know, highly paid, many times highly specialized physician and they're not sure what to do because
00:06:08
Speaker
We are taught mistakes, you know, are not to be made by human beings.
00:06:15
Speaker
Mistakes are errors and systems many times.
00:06:18
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And that's true.
00:06:19
Speaker
But also how to be able to deal with the problem.
00:06:23
Speaker
So I believe that.
00:06:26
Speaker
The first thing a physician should know is understand what the hospital's disclosure program is.
00:06:32
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Majority of hospitals in the United States should have disclosure programs and being familiar with it is important.
00:06:40
Speaker
And I can tell you as a young practicing physician, I had no idea what my hospital's disclosure program was.
00:06:48
Speaker
And only since I've become more interested in the topic and developed an expertise in it, I recognize that it's an important part of the process of working at any institution, especially if you're practicing in a litigious climate as we are in the United States.
00:07:07
Speaker
So I think that before we move to the next step, I think that what you're pointing out is very important in terms of each of our listeners should be familiar with the program for disclosures at their local hospital if there is one.
00:07:20
Speaker
I would assume that a lot of our practitioners are not aware of the existing program.
00:07:26
Speaker
It is also possible that many hospitals don't have a very robust program, but I think that is something that we as intensivists should really be aware of and if not present,
00:07:37
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maybe encourage the hospital and help develop.
00:07:40
Speaker
So clearly having a systematic framework of how we approach these disclosures and these errors is very important.
00:07:49
Speaker
What would be other components that you would recommend, Nitin, for us?
00:07:54
Speaker
So once you recognize an error has occurred, in an ideal situation, you would have the opportunity to reach out to patients
00:08:06
Speaker
a risk management or legal team who would start a process of reviewing what had occurred and also set up an independent time and also have a framework for you to be able to communicate with the family about and or and or patient about the mistake or problem which had occurred.
00:08:28
Speaker
What that allows you to do is have a safe space
00:08:32
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where you can sit down and you can have a conversation about if a mistake occurred, what, why it occurred, you know, when it occurred, how it occurred.
00:08:45
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And it provides the family an open forum to ask questions.
00:08:50
Speaker
It provides the physician an open forum to respond to questions, but leaving both the psychological burden on both sides.
00:08:59
Speaker
And it provides a framework
Institutional Support and Models for Transparency
00:09:00
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for discussion going forward as opposed to the way this process normally occurs is that a medical error occurs.
00:09:11
Speaker
The physician feels uncomfortable talking about it, may contact risk, may not contact risk.
00:09:18
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There's silence.
00:09:21
Speaker
A poor outcome may occur.
00:09:24
Speaker
it's unclear you know if there's ever any resolution or if people learn of that outcome can be prevented in the future and I want to say that's probably the old model what I'm referring to you know there's a survey I think probably in the early 2000s surveyed about 2,600 physicians and they said 98% of physicians at that time this is the early 2000s said that they would disclose a medical error and
00:09:51
Speaker
But only 50% of them would actually call it an error.
00:09:56
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Another 48% of them would call it an adverse event that occurred, not necessarily assigning blame for the error.
00:10:07
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So we believe errors occur.
00:10:09
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Most physicians believe that we should apologize and embrace it.
00:10:13
Speaker
Having the language, understanding, having that gray area, which is previously referred to,
00:10:20
Speaker
our other podcast of saying okay is this an error that I committed or is this an error based on the system and that's an adverse event and whether the physician should say that I committed a mistake or did not commit a mistake it's just it gets very difficult gets very gray and that's why you need to have a framework in place at the hospital or in your practice to be able to talk about
00:10:51
Speaker
Now, I think that the tendency, Nitin, would obviously be moving towards full disclosure, which really is about transparency with patients.
00:10:58
Speaker
And there are several studies that also seem to suggest some of the elements that are important from the patient perspective.
00:11:05
Speaker
But in terms of when to disclose the error, obviously, you want to be within the framework.
00:11:11
Speaker
You want to be a
00:11:13
Speaker
I think there's a tension between the time sensitivity of not waiting for four months and not doing immediately without the right support.
00:11:22
Speaker
So I think that that's where getting in contact with the people at risk management or other people who could support you at your individual hospital becomes important.
00:11:30
Speaker
But there's also some time sensitivity to this in terms that you would want to be able to provide information as soon as possible in terms of what happened, what are the consequences.
00:11:40
Speaker
And most importantly, I think, are
00:11:43
Speaker
What are we going to do to mitigate those consequences in the individual patient?
00:11:46
Speaker
But also, I think, and we can comment on this, families are very interested in patients and learning what are we doing to this won't happen again in the future.
00:11:57
Speaker
Well, I think you're exactly right.
00:11:59
Speaker
And, you know, I don't believe.
00:12:02
Speaker
you know, contacting risk management and then taking a week or 10 days to speak to the family would be appropriate.
00:12:09
Speaker
Like, you know, within 24 hours, having a sit down with the family or patient about what occurred would be ideal.
00:12:19
Speaker
Sometimes that's not possible.
00:12:22
Speaker
But, you know, one of the key elements from this is also learning, right?
00:12:32
Speaker
that you learn why the mistake occurred.
00:12:36
Speaker
Is it a system issue?
00:12:37
Speaker
Is it a personal responsibility issue?
00:12:41
Speaker
And also the patient's family's understanding why it occurred and hoping that in the future that this won't occur.
00:12:48
Speaker
You know, the person who really deserves a lot of credit for helping build or improve the patient
00:13:00
Speaker
experience for medical errors and physician experiences.
00:13:04
Speaker
A
Ethical Considerations and Apologies
00:13:05
Speaker
gentleman at the University of Michigan who actually just recently retired, Richard Boothman, and he said he distilled it down into three processes.
00:13:14
Speaker
If, you know, at the University of Michigan, if a medical error was made and it was due to negligence based on the physician, the physician or the institution would wrong, apologize, and quickly settle with the family.
00:13:28
Speaker
They felt like they were right in New York State of Michigan.
00:13:31
Speaker
They would stand up for their medical provider and litigate as necessary.
00:13:36
Speaker
But the third element was that they would learn from every medical error which occurred.
00:13:41
Speaker
So the point is, what I'm trying to say is, if an error occurs, because of that initial moment of panic, and the fight or flight response, some people will want to just go and tell the family, I made an error, I'm sorry.
00:13:57
Speaker
Another provider would just want to walk away and not think about it and come back later.
00:14:03
Speaker
But you oftentimes need somebody to talk to to help you organize your thoughts in that moment.
00:14:09
Speaker
Absolutely.
00:14:10
Speaker
And let's talk a little bit about once we're ready to talk with the family, some of the elements that I think are important from your perspective and making sure that it's done in the best way possible.
00:14:25
Speaker
Can you talk about that a little bit, Nitin?
00:14:28
Speaker
Definitely so you know if a When you're gonna disclose your medical error and you're sitting down in a room with a family to have this conversation it shouldn't be first of all a hallway discussion it should be that you're sitting in a room to have a appropriate discussion you want to state the nature of the mistake you would like to if you Believe that you made a mistake you want to be able to express personal regret and apologize and
00:15:00
Speaker
answer questions.
00:15:03
Speaker
But you know you want to avoid conjectures, subjective information, you know speculation and or of blame.
00:15:14
Speaker
And the reason for that is is that you want to just state the facts as they are.
00:15:20
Speaker
Apologize that you know something
00:15:24
Speaker
unexpected may have occurred to somebody's loved one or to the patient themselves but also embrace the whole process.
00:15:33
Speaker
Now this is very difficult.
00:15:34
Speaker
You know this isn't necessarily taught to physicians.
00:15:38
Speaker
And again, that's part of the reason there needs to be programs.
00:15:42
Speaker
Again, I don't know how many institutions have programs.
00:15:45
Speaker
I think it's something like 36 states have disclosure laws where disclosures are inadmissible in court.
00:15:54
Speaker
But again, you know, those laws have gray areas.
00:15:56
Speaker
So I believe that a physician having counsel for risk management is important.
00:16:05
Speaker
And I think that other than counseling, risk management, there's two important distinctions.
00:16:11
Speaker
One of them is
00:16:13
Speaker
the effect of, or actually the aspect of a disclosure that's just good patient care from an ethical perspective.
00:16:20
Speaker
Patients and families need to know what's happening with their care and what has happened, right?
00:16:25
Speaker
And then the other aspect, I mean, which I think is a big barrier, is the fear that physicians have that that disclosure might actually increase the risk of litigation, right?
00:16:36
Speaker
Now, it's very interesting, and you mentioned the University of Michigan, they have a very aggressive and systematic approach to medical errors, and they have found and published that by doing it the way you said, by very quickly speaking with families, recognizing the responsibility, and settling and compensating families appropriately, have found that their costs and number of litigations have gone down significantly over time.
00:17:03
Speaker
That doesn't mean that that's true for every single case, but I think at least in some of the literature that's out there, it would seem that in that effective disclosure done in a transparent way, if anything, does not increase the rate of the rate of litigation, but if anything, it might make it less.
00:17:20
Speaker
Any comments on that?
00:17:22
Speaker
Yeah, the literature is very clear about this, that, um,
00:17:26
Speaker
Empathetic, honest, straightforward interactions appears to significantly decrease the rate of litigation and the amount of malpractice claims.
00:17:39
Speaker
I mean, I think Michigan has some amazing numbers.
00:17:43
Speaker
Michigan specifically that they went from somewhere near 250 to 300 cases a year down to 100 cases a year when they implemented their program, organized program of dealing with medical errors.
00:17:57
Speaker
And what they also found is that some cases they settled prior to 2001 when they started their process.
00:18:05
Speaker
They would not have settled.
00:18:06
Speaker
And when I say some, the numbers they've quoted is something like 50% of the cases they would not have settled.
00:18:12
Speaker
So the point about this is, you know, you are correct, is that it's the ethical thing to do.
00:18:21
Speaker
It's what we're supposed to do as physicians.
00:18:23
Speaker
It's just the concern we have as physicians is that will my livelihood be threatened?
00:18:30
Speaker
Will my reputation be so tarnished that I will be unable to practice medicine?
00:18:35
Speaker
Which is what the example you brought up with the Yale CT surgeon.
00:18:40
Speaker
And that's why there needs to be a framework and a process to be able to protect physicians so we can, you know, do our job and also
00:18:53
Speaker
be responsible to the public in a manner that the public expects of us.
00:19:00
Speaker
And I think going back to the disclosure itself, I mean, the actual doing of it, like you said, most physicians, when asked, agree that it's the right thing to do.
00:19:13
Speaker
Yet when it happens, because of the lack of preparation, because of all the things that you mentioned as barriers, it probably doesn't happen as often as it should.
00:19:24
Speaker
And I think that's the big, I mean, performance gap that we need to improve as physicians.
00:19:29
Speaker
And to that, there's responsibility from the providers.
00:19:32
Speaker
and doing the right thing and learning about this, the programs that they have at their institutions.
00:19:36
Speaker
But also, like you said, there's a responsibility on our training programs, on institutions, and providing frameworks and education for physicians.
00:19:45
Speaker
Could you talk about some of the aspects, Nithin, of you mentioned a little bit about making sure that you state the nature of the mistake.
00:19:54
Speaker
So very, very clear and plain language, I presume, what happened, why it happened,
00:20:00
Speaker
and then what are the consequences?
00:20:03
Speaker
And can you talk a little bit about what are some of the elements that we should be paying attention to when we do this?
00:20:10
Speaker
100%.
00:20:10
Speaker
First, I believe you should use simple language.
00:20:13
Speaker
You should be precise.
00:20:16
Speaker
You should not, again, like I stated earlier, should avoid conjecture and blame.
00:20:23
Speaker
You know, an example may be,
00:20:28
Speaker
you know, I missed the patient's potassium being elevated and the patient has renal insufficiency and I gave a Asinibra causing a dangerous level hyperkalemia.
00:20:43
Speaker
Now, if the patient doesn't have any cardiac arrhythmia and you're able to bring the hyperkalemia down,
00:20:52
Speaker
always comes the question do you disclose to the family that you made a mistake and that's a huge gray area for physicians is because they sometimes believe if there's no harm that disclosure should not occur and I think that's a mistake I think that physicians need to be straightforward but again they need to have the framework and the language to talk about it and they need to have people who are trained in
00:21:15
Speaker
mediation and conflict resolution to help them because you can't go to a seminar and know exactly what to do.
00:21:24
Speaker
You need to have practice in this regard and I think intensivists are uniquely situated to be able to deal with this because oftentimes
00:21:35
Speaker
Our patients are critically ill.
00:21:36
Speaker
Sometimes there's mistakes that brought them to the intensive care unit.
00:21:40
Speaker
We are trained to have difficult conversations.
00:21:43
Speaker
So I do believe it should be an integral part of critical care training programs.
00:21:47
Speaker
We've integrated it into our program at Cooper and Kent in New Jersey.
00:21:53
Speaker
What about the...
00:21:56
Speaker
You talked about the provider expressing their personal regret and apologizing.
00:22:02
Speaker
So
Communication and Documentation Practices
00:22:03
Speaker
that is something that for many years, I think, in medicine,
00:22:08
Speaker
People have talked about not apologizing.
00:22:10
Speaker
I mean, that it's almost like a put yourself at risk.
00:22:13
Speaker
But I do think that the literature seems to show that sincere empathy, sincere compassion with what's happening is an important component of what patients and families want.
00:22:25
Speaker
Can you talk a little bit more about that?
00:22:28
Speaker
Yeah, I believe that the medical literature is very clear is that families want the truth.
00:22:36
Speaker
And for us to retain the confidence of the general public that we need to โ they need to have trust in us.
00:22:48
Speaker
I believe the most trusted profession in the United States is nursing.
00:22:53
Speaker
And then I believe physicians are in the top five.
00:23:00
Speaker
I want us to be the most trusted profession in the United States and if the public knows that they're going to get the truth from us, then I think that they will actually be more trusting of us as opposed to less trusting.
00:23:15
Speaker
You know, a little piece of trivia is in the early 2000 things, 2005, 2006, then Senators Barack Obama and Hillary Clinton tried to create legislative framework to say that there are three elements
00:23:30
Speaker
to dealing with medical errors.
00:23:32
Speaker
And one of them was is that medical errors should be disclosed by the physician and they should be protected when they disclose it and offer their apology.
00:23:43
Speaker
Now, all of that legislation didn't go through.
00:23:45
Speaker
It seems like that is the general mindset of practicing medicine in the United States today.
00:23:53
Speaker
So I believe not only for the psychological health of the patient
00:24:00
Speaker
the physician, but for general trust in those, for those who practice medicine support, to be honest and express regret when mistakes are made and also acknowledge when there are system errors that have occurred, but to avoid conjecture and blame.
00:24:14
Speaker
And then documentation is a big part.
00:24:17
Speaker
So before we go to documentation, I just want to probe this a little bit more in terms of the apology.
00:24:23
Speaker
I think this is a very important point.
00:24:25
Speaker
And I was reading about this topic, Nitin.
00:24:30
Speaker
I found some interesting studies that actually looked at โ there's two aspects to an apology.
00:24:36
Speaker
One of them involves โ
00:24:38
Speaker
the person giving the apology.
00:24:40
Speaker
So it's centered on the person apologizing.
00:24:43
Speaker
And that would be more like getting something off your chest.
00:24:46
Speaker
So there's obviously a relief after you apologize after doing a medical error.
00:24:51
Speaker
But there's also the other aspect, which is more of the patient-centered or the external person-related factors.
00:24:59
Speaker
And people have looked at this
00:25:00
Speaker
And clearly, an apology is always viewed in a positive, more than negative way.
00:25:06
Speaker
But when the physician is able to acknowledge what the patient is going through and introducing to their apology truth, empathy, and compassion, it's perceived in a much more positive way.
00:25:20
Speaker
Any comments or tips you can give us in that respect?
00:25:25
Speaker
Yeah, I believe you stated it very clearly and I don't have a lot more to add to that.
00:25:33
Speaker
I can just tell you that knowing you for many years, I think you have a very good way with people and understanding the delicate nature of the psyche of caregivers for the critical healing patients themselves.
00:25:50
Speaker
The fact that the caregivers and the patients would be with a physician who's forthright, people embrace that.
00:25:59
Speaker
And actually, in reality, it's not necessarily in the critical care literature, but in the general medical literature.
00:26:06
Speaker
And also, it's been shown both by malpractice claims that this is an important part of
00:26:15
Speaker
the process of both for healing for the patient and the caregiver.
00:26:20
Speaker
It's also fascinating though if you read Richard Boothman's you know some of the literature he's written or been a part of he talks about that the apology to him is not as important as the fact that when people acknowledge their mistakes then patient safety improves.
00:26:42
Speaker
So
00:26:44
Speaker
It's important for people to acknowledge they made a mistake so we can all or the system is flawed.
00:26:50
Speaker
So overall, the care for patients can improve.
00:26:53
Speaker
And I think patients and families feel better when they feel like others won't be hurt in the future.
00:26:59
Speaker
You know, it's progress.
00:27:02
Speaker
And I think that those are two important, there's two important aspects about the learning part and our disclosure.
00:27:09
Speaker
One of them you talked about right now, which I think is important that families be told, what else are we going to do and follow up to make sure this doesn't happen not only to them again and their loved one, but to other patients.
00:27:20
Speaker
I think that's very, very important.
00:27:23
Speaker
And I think that you just made that point very clearly.
00:27:26
Speaker
And I think the other part of this is also when we acknowledge there's been a mistake is being very clear on what are the immediate actions that we're taking to mitigate the effects of that mistake on the patient.
00:27:41
Speaker
Exactly.
00:27:41
Speaker
I mean, the families want to know in their immediate moment, they want to know that their loved one is all right.
00:27:48
Speaker
And I think that
00:27:51
Speaker
You know, initially, if there's concern that, you know, these physicians or the care team doesn't know what they're doing over a period of time, they'll see that if you're honest and you are able to care for their loved one, that the sense of trust will be heightened and improved.
00:28:07
Speaker
It's
Training and Roles in Error Disclosure
00:28:08
Speaker
about building relationships.
00:28:09
Speaker
You know, we, our job as intensiveness is we take somebody we may never met before and they come into us, you know, sometimes knocking on death's door and if we're able to get them better, that's good.
00:28:21
Speaker
If we're not able to get them better, then we make sure there's not pain and suffering.
00:28:24
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But you have to build a trusting therapeutic relationship and being honest with people is one of the foundations of that relationship.
00:28:32
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Absolutely.
00:28:33
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Now, you did mention about documentation, and I think that that is obviously also a very tricky and difficult part.
00:28:41
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People are always concerned about what they write on charts.
00:28:45
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But the first thing you mentioned at the beginning of the podcast was make sure that you understand what is the policy and what is the disclosure program at your hospital, because many hospitals might have actually a documentation form for the chart, correct?
00:28:59
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Correct.
00:29:02
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That is correct.
00:29:03
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And I think that, you know, depending on where you practice or you practice at multiple hospitals, there likely are multiple policies and procedures about this because it varies not only from state to state.
00:29:16
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It may vary from hospital to hospital with some common themes that, you know, you should engage the risk management department.
00:29:27
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You should engage the family as soon as possible.
00:29:32
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you should document.
00:29:33
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And so the element of documentation is important.
00:29:36
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I think some basic elements of documentation is, you know, documenting the time, date and place of discussion, you know, what was communicated in the conversation, you know, the names and relationships of the families and that
00:29:55
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everyone in the room understood what was going on.
00:29:57
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So using simple, plain, clear language.
00:30:01
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And that is, you know, reflective of the policy of the hospital where I practice that currently.
00:30:10
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But it was different at previous institutions where I practiced.
00:30:13
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And so I think that knowing what the policy is at your specific institution plays a large role in this.
00:30:20
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But then also if you find it unsatisfactory to engage the institution.
00:30:24
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Because for these programs to be successful, the institution's need
00:30:30
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champions and need people to advocate for these programs.
00:30:35
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And, you know, when you advocate and have successful programs, you know, it's not just the University of Michigan.
00:30:43
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A place like Henry Ford in Michigan talked about decreasing their malpractice claims by over 60%, you know, from 45 million down to something like 15 million over an eight-year period.
00:30:54
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But that's because they had an organized program and disclosure as part of
00:30:59
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And I think that as part of that program, also an element that you had mentioned earlier, Nitin, would be appropriate education.
00:31:04
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But if the institution is not providing that education, I think it's upon us to try to seek that education and try to lobby our local hospitals and our C-suites to really push this forward.
00:31:17
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Because I think it's not only an important topic now, but I think it's going to keep a growing in relevance as we move forward into a value-based healthcare system.
00:31:31
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And I'll just say, Sergio, you know, obviously grateful for what you're doing with this podcast.
00:31:37
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Intensivists are in a prime position to be able to have these conversations because having difficult conversations is part of our job description.
00:31:45
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Yeah.
00:31:46
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And I think that one of the aspects that we that we didn't touch on that I want to touch on that I think are unique to to our world of critical care or not unique, but maybe more prevalent is
00:31:56
Speaker
One of them is understanding the concept of the team and really doing this as a team.
00:32:01
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And differentiation with our critical care nurses and physicians that I have found very interesting and it was brought to me in practice by one of our colleagues, our nursing colleagues, was that a lot of times when a medical error occurs, the medical team doesn't really have to engage with the patient and the family immediately after that happens sometimes.
00:32:23
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They have time to
00:32:24
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kind of regroup and try to figure out what the next step is.
00:32:28
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But our nurses who are caring for that patient for 12 hours straight don't have that luxury.
00:32:35
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So they're still having to care with it, with the, it's caring for that patient and interacting with the family immediately.
00:32:39
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And I think it's important for us to have that, that, that empathy for our nurses, because a lot of times they might be part of the error in terms of a wrong medication given or a wrong dose, which may have not been necessarily their fault.
00:32:53
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There's a system error, but they are right there and they can't really hide anywhere.
00:32:58
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So I think it's important.
00:33:00
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Any comments on that distinction?
00:33:03
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Yeah, no, no, it's a very important distinction.
00:33:05
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You know, our nurses, I think the data shows that clinical providers, whether physician, you know, resident, med student, PA, whatever it may be, we're with the patients 2% of the time and the nurses are with the patient 98% of the time.
00:33:23
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And so I think it's important that the nurses feel free to openly discuss with the medical team what had occurred, but also feel free to embrace the family, advocate for the family, and the family feels that they have a
00:33:46
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Resource for their loved one or the patient feels like they have a resource for themselves.
00:33:51
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I do believe that Open and honest discussions about medical errors are important but I
00:34:00
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would also counsel to avoid conjecture, blame, and subjective information such as, oh, the resident did it and the attending inappropriately supervised whatever procedure occurred.
00:34:14
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You know, I don't think that that's the right way to go, but to say, you know, I'm sorry this occurred.
00:34:19
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We're going to do everything we can to get your loved one through it and we want to be there for you.
00:34:25
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And, you know, the nurses have always had
00:34:28
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medical providers' backs, the clinical providers as far as physicians and the rest of the clinical team.
00:34:35
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And we need to be grateful to them.
00:34:39
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And I think that the second aspect that I wanted to touch on, which I think is maybe a common occurrence for intensivists, is that a lot of times we will be taking care of a patient or there might be errors that occurred outside of our care that have led the patient to the ICU.
00:34:56
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And I think that a topic that maybe merits a little bit of discussion is how do we disclose errors caused by other people that are not in the same hospital or that not in the same team when we're caring for those patients.
00:35:10
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Any comments there, Nitin?
00:35:12
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Yeah, this is a very common phenomenon.
00:35:16
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And I uniformly caution my trainees or colleagues that
00:35:23
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to avoid the dismissive attitude or the pointing a finger of blame at outside facilities or physicians from our providers outside the intensive care unit because we're all human and we all make mistakes.
00:35:44
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Many times families are angry.
00:35:47
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They're concerned about the care that the loved one received prior to coming to the intensive care unit.
00:35:52
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And I think we owe it as a duty and responsibility to inform the prior institution if that occurred or, you know, our colleagues outside of the intensive care unit, again, engaged in a positive conversation or structured conversations with the families about what occurred, what we're able to do and not do.
00:36:15
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sometimes you find that the care was appropriate, families are just upset or the patients just upset because it's an upsetting situation but working together to focus on the family's experience being positive as much as it can be, the patient's experience being positive as much as it can be, and to avoid
00:36:40
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you know, looking down or blaming other institutions, I think is just generally a good rule, the golden rule, don't speak illy of others.
00:36:48
Speaker
Yeah.
00:36:49
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So I think we talked a little bit about the disclosure of the Medicare to patients and families, and we'll summarize that in a moment.
00:36:57
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We talked about documenting in the chart, and I think that what's important is that the perfect situation
00:37:05
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is that a medical error does not occur, obviously.
00:37:08
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But when it does occur, I think that full disclosure within a systematic approach with a program at your institution is probably the most important thing.
00:37:19
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That has to be paired with proper documentation.
00:37:23
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One without the other is incomplete, right?
00:37:25
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You just can't write in the chart and not tell the family.
00:37:28
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You can't tell the family
Learning from Errors and Resources
00:37:29
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and not document it.
00:37:30
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So you need both.
00:37:31
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And I think that's important.
00:37:32
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But the third element I wanted to ask you about, Nitin, which is really about
00:37:36
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moving the safety culture forward and improving care for our patients, how do we report this to our peers?
00:37:43
Speaker
I mean, it would be ideal if there was self-reporting on medical errors to peer reviews, to your filter committees, to your M&Ms.
00:37:52
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It does not happen, I'm sure, in many hospitals.
00:37:54
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But what are your thoughts on how do we move that forward?
00:37:57
Speaker
Yeah, that's a great topic.
00:38:01
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You know, it starts with the peer review process that's not punitive.
00:38:07
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and not a witch hunt but actually a peer review process that focuses on helping providers grow and learn and creating remedies or corrective actions for providers who've made mistakes prior to them you know being at a place where
00:38:31
Speaker
a lot of times by the time physicians get to peer review, they're at the end of their rope.
00:38:37
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They are people who may have been making mistakes for years and the mistakes just became so egregious that they made it to peer review.
00:38:46
Speaker
And then those providers don't have the ability to improve, get better, and remain part of medical practice.
00:38:58
Speaker
You know,
00:38:59
Speaker
So really it's very important for the risk management legal team that's part of the medical error review process to work also with the peer review team and have a strong physician champion to assure that peer review is an open process where people are able to talk about mistakes, morbidities, mortality, and open ways so people can embrace and improve their skill set as opposed to a punitive process.
00:39:28
Speaker
where people have fear about loss of livelihood and loss of being able to practice their profession.
00:39:35
Speaker
Absolutely, and I think it's something that takes time, but I think as intensivists who might be involved in peer review, involved in M&Ms, really trying to move towards a learning environment where the real objective is to improve ourselves as providers, but also improve care of patients away from that punitive kind of mentality is very important.
00:40:00
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And I think it's a journey, but clearly something that our patients would appreciate.
00:40:06
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I agree.
00:40:08
Speaker
I think one of the things, one of the tools that the Agency for Quality and Healthcare Research had put about $30 million to researching this topic.
00:40:20
Speaker
And we were able to come up with the CANDOR toolkit, which is the Communication and Optimal Resolution Toolkit.
00:40:30
Speaker
And a lot of things we've spoken about today are detailed there.
00:40:35
Speaker
And I think that that's a good tool for any intensivist to take or a good website for anyone to any intensivist to take a look at.
00:40:43
Speaker
And trainees should be familiar with that.
00:40:46
Speaker
And not necessarily watch all the videos on the website, but be aware that resource does exist and not just use it right when you have problems or prior.
00:40:54
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So you have problems.
00:40:56
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psychological framework to be able to deal with it appropriately.
00:40:59
Speaker
And that is, like you said, a very well designed toolkit and we'll definitely reference it in the show notes.
00:41:05
Speaker
I think that in summary, I think that some of the elements that you have touched on, Nathan, before we go to some of the closing questions, relate to the fact to understanding
00:41:16
Speaker
locally, what is the program that exists as your hospital.
00:41:20
Speaker
If one does exist, become familiar with it.
00:41:22
Speaker
If it doesn't, maybe you should be lobbying to create one.
00:41:25
Speaker
But understanding what are the resources available to you locally.
00:41:28
Speaker
And then I think that in terms of doing this the right way, you talked about disclosing that an error has occurred in very plain language, explaining the nature of the mistake, what are the consequences for the patient.
00:41:42
Speaker
What are the corrective actions that we're taking to mitigate the effects?
00:41:46
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Expressing personal regret and apologizing for what the patient and the family is going through.
00:41:52
Speaker
Making sure that we elicit questions and make sure that they understand.
00:41:56
Speaker
making sure that there are an opportunity for family to ask questions and patients and that we address them.
00:42:02
Speaker
And I think that the last part is to making sure that we tell them what are the steps that we're going to take further to make sure it never happens again to their loved one, to themselves, or to other patients.
00:42:13
Speaker
So I think that's a very useful framework that we touched about.
00:42:17
Speaker
Now, as we close, Nathan, you're familiar with our format.
00:42:22
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You've been at Critical Matters before.
00:42:23
Speaker
We usually like to ask some questions not related to the topic that we're discussing.
00:42:28
Speaker
But since we've done that with you already, what I wanted to know is, are there any resources other than the candor resources that you mentioned or books or articles that you recommend to our listeners specifically as they relate to the topic that we discussed today?
00:42:43
Speaker
I think it's important to be familiar with two resources.
00:42:52
Speaker
The Richard Boothman interview, he's a lawyer from University of Michigan, who's recently retired, who helped organize the process in University of Michigan, which became sort of a model for many places in the country.
00:43:02
Speaker
He has a nice interview with our
00:43:06
Speaker
Dr. Watcher.
00:43:08
Speaker
And that's, you know, it could take somebody 15 minutes to read that, but it will change your perspective of medical errors and how we deal with them.
00:43:15
Speaker
So I think that that's an important resource to be familiar with.
00:43:18
Speaker
And then I think, obviously, as an intensivist, we all are familiar with what is going on with
00:43:31
Speaker
going on in New York with sepsis care and to be aware that that came out of a problem for the care of a young boy, Rory Stanton, in New York and the care that was provided for him and that is leading to the way we care for septic patients all around the United States and the world.
00:43:56
Speaker
And just to be familiar with Rory Stanton's story,
00:44:00
Speaker
because it really can just be one instance that can lead to the change of the way we care for patients.
00:44:10
Speaker
Absolutely.
00:44:11
Speaker
And I think that along those lines, I'm very interested in the behavioral aspects, the cognitive aspects of how sometimes we are deceived by our intuitions and how very smart people can be fooled into making mistakes or not admitting their mistakes.
00:44:31
Speaker
And to that effect, there's a book, Nathan, called Mistakes Were Done But Not By Me.
00:44:37
Speaker
why we justify foolish beliefs, and I'll put it in the show notes, which I think is very interesting in terms of how we deal with mistakes and this cognitive dissonance that occurs when bad things happen and how we fool ourselves into really not disclosing, not admitting.
00:44:54
Speaker
And I think it's just, I mean, interesting how sometimes our intuitions really fool us and lead us down the wrong path here.
00:45:04
Speaker
I could not agree more.
00:45:06
Speaker
I think that anybody who thinks that they don't make mistakes is a dangerous person, and I look forward to reading the resource.
00:45:16
Speaker
So the last question I have for you, Nitin, is is there one thing in particular you would want every listener, every sound critical care provider and other intensivists listening to our podcast to know about the topic of disclosing medical errors?
00:45:32
Speaker
I would like...
00:45:33
Speaker
to everyone to know that we all make mistakes and it's all right and we can learn from them and improve patient care.
00:45:43
Speaker
Absolutely.
00:45:44
Speaker
And I think this is a topic that I'm sure will lend to more and more discussions.
00:45:48
Speaker
I really appreciate your time and being willing to come again and dive a little bit deeper into the disclosure aspect, Nitin.
00:45:55
Speaker
And always a pleasure to talk with you.
00:45:57
Speaker
Thank you so much.
00:45:58
Speaker
Thanks, Sergio.
00:46:00
Speaker
You take care of yourself.
00:46:01
Speaker
Bye-bye.
00:46:04
Speaker
Thanks again for listening to Critical Matters.
00:46:06
Speaker
Make sure to subscribe to this podcast on iTunes or Google Play.