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Entering the Second Decade of the Patient Safety Movement: The Field Matures: Comment on Disclosure of Hospital Adverse Events and Its Association With Patients' Ratings of the Quality of Care

Entering the Second Decade of the Patient Safety Movement: The Field Matures: Comment on... December 1, 2009, marks the 10-year anniversary of the Institute of Medicine report on medical mistakes, To Err is Human, the blockbuster that launched the modern patient safety movement.1,2 The occasion of this anniversary gives us an opportunity to reflect on the progress we have made in patient safety and on areas that have not received the attention they deserve. The Institute of Medicine report that popularized the statistic that 44 000 to 98 000 Americans die each year as a result of medical errors (“a jumbo jet a day”) unleashed a variety of pressures to improve patient safety. Perhaps most importantly (particularly in the early years), accreditation and regulation became far more aggressive.3 For example, the Joint Commission (previously the Joint Commission on Accreditation of Healthcare Organizations), launched a program of unannounced hospital surveys and began promoting and enforcing a variety of “National Patient Safety Goals.”4 The Accreditation Council on Graduate Medical Education enacted duty hour limits for residents and began emphasizing “systems-based practice” in training curricula,5,6 and a majority of US states began requiring reporting of serious adverse events.7 In other areas, progress came more slowly. Despite evidence that computerization could prevent many kinds of medication errors, relatively few hospitals and clinics installed sophisticated information technology systems.8 The emphasis on a systems-focused, “no blame” environment began conflicting with increasing pressure for individual and organizational accountability.9,10 Finally, some key areas in patient safety were all but ignored in the early years. This issue of Archives contains articles that promote our understanding of 2 of the most important topics in this category: disclosure of adverse events to patients and diagnostic errors. Let us begin with disclosure of adverse events to patients. Before the safety movement, most physicians hesitated to disclose medical errors to patients, fearful that such disclosure would increase the risk of a lawsuit.11 Over the past several years, research has indicated that disclosure may not increase, and might even decrease, the risk of being successfully sued.12 The majority of US states have passed laws protecting apologies from being used in subsequent litigation.13 The National Quality Forum has endorsed disclosure as a “safe practice,” and the Joint Commission now requires hospitals to mandate disclosure and to support the practice with educational programs.4,14 The latter point is important: although some disclosure is limited by providers' shame or fear of malpractice, physicians are also uncertain about how to perform disclosure effectively; they respond to education with more and better disclosure.15 Although there is clear evidence from surveys that patients want to be told the truth about medical mistakes, there is little empirical evidence about what happens when they are told. The article by López and colleagues reviews Massachusetts' experience with adverse event disclosure. The study found that, while only 40% of all adverse events were disclosed to patients, overall quality-of-care ratings were higher when disclosure did occur. López and coauthors' study has some important limitations. Their sample comes from 2003, before there were significant pressure for disclosure, literature on disclosure and liability, and published information about best practices in disclosure. Both adverse events and the presence and content of provider disclosure of such advents were ascertained through patient self-reports. Notwithstanding these limitations, the article by López and colleagues adds to the accumulating evidence that disclosure is not only ethically correct but, if done well, can lead to higher levels of patient trust, increased perceptions of quality, and perhaps even lower malpractice risk. A second area that was underemphasized in the first few years of the safety field was diagnostic error.16,17 Instead, the field focused on errors thought to be amenable to systems solutions, such as medication errors, health care–associated infections, and wrong-site surgery. Moreover, physicians may have been more reluctant to discuss diagnostic errors than other types of errors because they viewed diagnostic errors as being more closely associated with their own cognitive failings than errors that feel more “system-ish.” Yet we know that diagnostic errors are frequent and morbid. They are among the most common sources of malpractice cases, and modern autopsy studies continue to find evidence of significant diagnostic errors that may have contributed to the death in approximately 1 in 10 cases.18,19 As with error disclosure, momentum to address the relative underemphasis on diagnostic error has been growing. Recent literature has described the frequency of diagnostic errors, some of the cognitive and systems-based solutions for these errors, and the importance of elevating such errors to their rightful place in the patient safety field.10,16,20-23 The Agency for Healthcare Research and Quality is promoting research in diagnostic errors, and a small group of experts has begun to host conferences and other collaborative initiatives. The study by Schiff and colleagues analyzes 669 cases of diagnostic errors reported by a convenience sample of 310 physicians. Consistent with other series, while missed diagnoses of pulmonary embolism and cancers were the most commonly reported mistakes, there was a wide range of missed diagnoses. The study characterizes the phases of care in which errors occur (most commonly in the testing phase [failure to order laboratory tests and to report or follow up on results], followed closely by clinical assessment errors [failure to consider or overemphasis of competing diagnoses]), and places them in a new, robust diagnostic errors taxonomy that can support error reporting and analysis. What can we learn from the studies by López et al and Schiff et al as we mark the 10-year anniversary of the modern patient safety movement? First, certain types of errors and safety-related practices—in this case diagnostic errors and error disclosure—were underemphasized in the early years of the movement because they were hard to measure, less amenable to “systems-based solutions,” and engendered fear or shame on the part of providers. Getting providers to disclose errors to patients and to discuss diagnostic errors openly requires the creation of supportive, safe environments, coupled with appropriate training. For error disclosure, such safe environments are bolstered by evidence that malpractice risk is not raised by disclosure, by laws that protect apologies from being used against physicians in litigation, by training programs in effective disclosure techniques, and by findings such as those of López and colleagues demonstrating that patients rate the quality of care higher when adverse events are disclosed. In the case of diagnostic errors, creating safe environments, such as in-person or online morbidity and mortality conferences,24,25 can help promote open discussions and learning. So can a common language (such as provided through the diagnostic errors taxonomy) and studies that demonstrate that diagnostic errors can be prevented through better training and decision support. In the end, both of these articles serve 2 vital roles: the fact of their publication demonstrates the continued maturation of the patient safety field, while their content helps advance this very maturation. Correspondence: Dr Wachter, Department of Medicine, University of California, San Francisco, 505 Parnassus Ave, Room M-994, San Francisco, CA 94143-0120 (bobw@medicine.ucsf.edu). Accepted for Publication: August 26, 2009. Financial Disclosure: Dr Wachter reports having an equity interest in and serving on advisory boards for Hoana Medical, Intellidot, and Doctor Evidence; serving on paid advisory boards for Google and Epocrates; receiving fees from QuantiaMD for helping to produce a Web-based series on patient safety and from the American Board of Internal Medicine for serving on its board of directors; and receiving funding under a contract from the Agency for Healthcare Research and Quality for editing 2 patient-safety Web sites and royalties from publishers from 2 books on patient safety. References 1. Kohn LCorrigan JDonaldson M To Err is Human: Building a Safer Health System. Washington, DC National Academies Press2000; 2. Wachter RM Understanding Patient Safety. New York, NY McGraw-Hill Co2007; 3. Wachter RM The end of the beginning: patient safety five years after “to err is human.” Health Aff (Millwood) 2004; ((suppl Web exclusives)) W4-534- W4-545PubMedGoogle Scholar 4. 2009 National Patient Safety Goals. The Joint Commission Web site. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/. Accessed August 22, 2009Google Scholar 5. Jagsi RWeinstein DFShapiro JKitch BTDorer DWeissman JS The Accreditation Council for Graduate Medical Education's limits on residents' work hours and patient safety: a study of resident experiences and perceptions before and after hours reductions. Arch Intern Med 2008;168 (5) 493- 500PubMedGoogle ScholarCrossref 6. Graham MJNaqvi ZEncandela JA et al. What indicated competency in systems-based practice? an analysis of perspective consistency among healthcare team members. Adv Health Sci Educ Theory Pract 2009;14 (2) 187- 203PubMedGoogle ScholarCrossref 7. Rosenthal J Advancing patient safety through state reporting systems. AHRQ WebM&M Web site. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=43. Accessed August 22, 2009Google Scholar 8. Jha AKDesroches CMCampbell EG et al. Use of electronic health records in US hospitals. N Engl J Med 2009;360 (16) 1628- 1638PubMedGoogle ScholarCrossref 9. Lee THMeyer GSBrennan TA A middle ground on public accountability. N Engl J Med 2004;350 (23) 2409- 2412PubMedGoogle ScholarCrossref 10. Wachter RMPronovost PJ Balancing “no blame” with accountability in patient safety. N Engl J Med 2009;361 (14) 1401- 1406PubMedGoogle ScholarCrossref 11. Gallagher THGarbutt JMWaterman AD et al. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Intern Med 2006;166 (15) 1585- 1593PubMedGoogle ScholarCrossref 12. Kachalia AShojania KGHofer TPPiotrowski MSaint S Does full disclosure of medical errors affect malpractice liability? the jury is still out. Jt Comm J Qual Saf 2003;29 (10) 503- 511PubMedGoogle Scholar 13. McDonnell WMGuenther E Narrative review: do state laws make it easier to say “I’m sorry?” Ann Intern Med 2008;149 (11) 811- 816PubMedGoogle ScholarCrossref 14. Safe practices for better healthcare—2009 update. National Quality Forum Web site. http://www.qualityforum.org/Publications/2009/03/Safe_Practices_for_Better_Healthcare–2009_Update.aspx. Accessed August 22, 2009Google Scholar 15. Gallagher TH A 62-year-old woman with skin cancer who experienced wrong-site surgery. JAMA 2009;302 (6) 669- 677PubMedGoogle ScholarCrossref 16. Newman-Toker DEPronovost PJ Diagnostic errors—the next frontier for patient safety. JAMA 2009;301 (10) 1060- 1062PubMedGoogle ScholarCrossref 17. Graber M Diagnostic error in medicine: a case of neglect. Jt Comm J Qual Patient Saf 2005;31 (2) 106- 113PubMedGoogle Scholar 18. Chandra ANundy SSeabury SA The growth of physician medical malpractice payments: evidence from the National Practitioner Data Bank. Health Aff (Millwood) 2005; ((suppl Web exclusives)) W5-240- W5-249PubMedGoogle Scholar 19. Shojania KGBurton ECMcDonald KMGoldman L Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA 2003;289 (21) 2849- 2856PubMedGoogle ScholarCrossref 20. Graber MLFranklin NGordon RR Diagnostic error in internal medicine. Arch Intern Med 2005;165 (13) 1493- 1499PubMedGoogle ScholarCrossref 21. Croskerry P Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med 2003;41 (1) 110- 120PubMedGoogle ScholarCrossref 22. Croskerry P The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003;78 (8) 775- 780PubMedGoogle ScholarCrossref 23. Redelmeier DA Improving patient care: the cognitive psychology of missed diagnoses. Ann Intern Med 2005;142 (2) 115- 120PubMedGoogle ScholarCrossref 24. Kravet SJHowell EWright SM Morbidity and mortality conference, grand rounds, and the ACGME's core competencies. J Gen Intern Med 2006;21 (11) 1192- 1194PubMedGoogle ScholarCrossref 25. Morbidity & mortality rounds on the Web AHRQ WebM&M Web site. http://webmm.ahrq.gov. Accessed August 22, 2009Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Entering the Second Decade of the Patient Safety Movement: The Field Matures: Comment on Disclosure of Hospital Adverse Events and Its Association With Patients' Ratings of the Quality of Care

Wachter, Robert M.
Archives of Internal Medicine , Volume 169 (20) – Nov 9, 2009
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References (27)

Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2009.351
Publisher site
See Article on Publisher Site

Abstract

December 1, 2009, marks the 10-year anniversary of the Institute of Medicine report on medical mistakes, To Err is Human, the blockbuster that launched the modern patient safety movement.1,2 The occasion of this anniversary gives us an opportunity to reflect on the progress we have made in patient safety and on areas that have not received the attention they deserve. The Institute of Medicine report that popularized the statistic that 44 000 to 98 000 Americans die each year as a result of medical errors (“a jumbo jet a day”) unleashed a variety of pressures to improve patient safety. Perhaps most importantly (particularly in the early years), accreditation and regulation became far more aggressive.3 For example, the Joint Commission (previously the Joint Commission on Accreditation of Healthcare Organizations), launched a program of unannounced hospital surveys and began promoting and enforcing a variety of “National Patient Safety Goals.”4 The Accreditation Council on Graduate Medical Education enacted duty hour limits for residents and began emphasizing “systems-based practice” in training curricula,5,6 and a majority of US states began requiring reporting of serious adverse events.7 In other areas, progress came more slowly. Despite evidence that computerization could prevent many kinds of medication errors, relatively few hospitals and clinics installed sophisticated information technology systems.8 The emphasis on a systems-focused, “no blame” environment began conflicting with increasing pressure for individual and organizational accountability.9,10 Finally, some key areas in patient safety were all but ignored in the early years. This issue of Archives contains articles that promote our understanding of 2 of the most important topics in this category: disclosure of adverse events to patients and diagnostic errors. Let us begin with disclosure of adverse events to patients. Before the safety movement, most physicians hesitated to disclose medical errors to patients, fearful that such disclosure would increase the risk of a lawsuit.11 Over the past several years, research has indicated that disclosure may not increase, and might even decrease, the risk of being successfully sued.12 The majority of US states have passed laws protecting apologies from being used in subsequent litigation.13 The National Quality Forum has endorsed disclosure as a “safe practice,” and the Joint Commission now requires hospitals to mandate disclosure and to support the practice with educational programs.4,14 The latter point is important: although some disclosure is limited by providers' shame or fear of malpractice, physicians are also uncertain about how to perform disclosure effectively; they respond to education with more and better disclosure.15 Although there is clear evidence from surveys that patients want to be told the truth about medical mistakes, there is little empirical evidence about what happens when they are told. The article by López and colleagues reviews Massachusetts' experience with adverse event disclosure. The study found that, while only 40% of all adverse events were disclosed to patients, overall quality-of-care ratings were higher when disclosure did occur. López and coauthors' study has some important limitations. Their sample comes from 2003, before there were significant pressure for disclosure, literature on disclosure and liability, and published information about best practices in disclosure. Both adverse events and the presence and content of provider disclosure of such advents were ascertained through patient self-reports. Notwithstanding these limitations, the article by López and colleagues adds to the accumulating evidence that disclosure is not only ethically correct but, if done well, can lead to higher levels of patient trust, increased perceptions of quality, and perhaps even lower malpractice risk. A second area that was underemphasized in the first few years of the safety field was diagnostic error.16,17 Instead, the field focused on errors thought to be amenable to systems solutions, such as medication errors, health care–associated infections, and wrong-site surgery. Moreover, physicians may have been more reluctant to discuss diagnostic errors than other types of errors because they viewed diagnostic errors as being more closely associated with their own cognitive failings than errors that feel more “system-ish.” Yet we know that diagnostic errors are frequent and morbid. They are among the most common sources of malpractice cases, and modern autopsy studies continue to find evidence of significant diagnostic errors that may have contributed to the death in approximately 1 in 10 cases.18,19 As with error disclosure, momentum to address the relative underemphasis on diagnostic error has been growing. Recent literature has described the frequency of diagnostic errors, some of the cognitive and systems-based solutions for these errors, and the importance of elevating such errors to their rightful place in the patient safety field.10,16,20-23 The Agency for Healthcare Research and Quality is promoting research in diagnostic errors, and a small group of experts has begun to host conferences and other collaborative initiatives. The study by Schiff and colleagues analyzes 669 cases of diagnostic errors reported by a convenience sample of 310 physicians. Consistent with other series, while missed diagnoses of pulmonary embolism and cancers were the most commonly reported mistakes, there was a wide range of missed diagnoses. The study characterizes the phases of care in which errors occur (most commonly in the testing phase [failure to order laboratory tests and to report or follow up on results], followed closely by clinical assessment errors [failure to consider or overemphasis of competing diagnoses]), and places them in a new, robust diagnostic errors taxonomy that can support error reporting and analysis. What can we learn from the studies by López et al and Schiff et al as we mark the 10-year anniversary of the modern patient safety movement? First, certain types of errors and safety-related practices—in this case diagnostic errors and error disclosure—were underemphasized in the early years of the movement because they were hard to measure, less amenable to “systems-based solutions,” and engendered fear or shame on the part of providers. Getting providers to disclose errors to patients and to discuss diagnostic errors openly requires the creation of supportive, safe environments, coupled with appropriate training. For error disclosure, such safe environments are bolstered by evidence that malpractice risk is not raised by disclosure, by laws that protect apologies from being used against physicians in litigation, by training programs in effective disclosure techniques, and by findings such as those of López and colleagues demonstrating that patients rate the quality of care higher when adverse events are disclosed. In the case of diagnostic errors, creating safe environments, such as in-person or online morbidity and mortality conferences,24,25 can help promote open discussions and learning. So can a common language (such as provided through the diagnostic errors taxonomy) and studies that demonstrate that diagnostic errors can be prevented through better training and decision support. In the end, both of these articles serve 2 vital roles: the fact of their publication demonstrates the continued maturation of the patient safety field, while their content helps advance this very maturation. Correspondence: Dr Wachter, Department of Medicine, University of California, San Francisco, 505 Parnassus Ave, Room M-994, San Francisco, CA 94143-0120 (bobw@medicine.ucsf.edu). Accepted for Publication: August 26, 2009. Financial Disclosure: Dr Wachter reports having an equity interest in and serving on advisory boards for Hoana Medical, Intellidot, and Doctor Evidence; serving on paid advisory boards for Google and Epocrates; receiving fees from QuantiaMD for helping to produce a Web-based series on patient safety and from the American Board of Internal Medicine for serving on its board of directors; and receiving funding under a contract from the Agency for Healthcare Research and Quality for editing 2 patient-safety Web sites and royalties from publishers from 2 books on patient safety. References 1. Kohn LCorrigan JDonaldson M To Err is Human: Building a Safer Health System. Washington, DC National Academies Press2000; 2. Wachter RM Understanding Patient Safety. New York, NY McGraw-Hill Co2007; 3. Wachter RM The end of the beginning: patient safety five years after “to err is human.” Health Aff (Millwood) 2004; ((suppl Web exclusives)) W4-534- W4-545PubMedGoogle Scholar 4. 2009 National Patient Safety Goals. The Joint Commission Web site. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/. Accessed August 22, 2009Google Scholar 5. Jagsi RWeinstein DFShapiro JKitch BTDorer DWeissman JS The Accreditation Council for Graduate Medical Education's limits on residents' work hours and patient safety: a study of resident experiences and perceptions before and after hours reductions. Arch Intern Med 2008;168 (5) 493- 500PubMedGoogle ScholarCrossref 6. Graham MJNaqvi ZEncandela JA et al. What indicated competency in systems-based practice? an analysis of perspective consistency among healthcare team members. Adv Health Sci Educ Theory Pract 2009;14 (2) 187- 203PubMedGoogle ScholarCrossref 7. Rosenthal J Advancing patient safety through state reporting systems. AHRQ WebM&M Web site. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=43. Accessed August 22, 2009Google Scholar 8. Jha AKDesroches CMCampbell EG et al. Use of electronic health records in US hospitals. N Engl J Med 2009;360 (16) 1628- 1638PubMedGoogle ScholarCrossref 9. Lee THMeyer GSBrennan TA A middle ground on public accountability. N Engl J Med 2004;350 (23) 2409- 2412PubMedGoogle ScholarCrossref 10. Wachter RMPronovost PJ Balancing “no blame” with accountability in patient safety. N Engl J Med 2009;361 (14) 1401- 1406PubMedGoogle ScholarCrossref 11. Gallagher THGarbutt JMWaterman AD et al. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Intern Med 2006;166 (15) 1585- 1593PubMedGoogle ScholarCrossref 12. Kachalia AShojania KGHofer TPPiotrowski MSaint S Does full disclosure of medical errors affect malpractice liability? the jury is still out. Jt Comm J Qual Saf 2003;29 (10) 503- 511PubMedGoogle Scholar 13. McDonnell WMGuenther E Narrative review: do state laws make it easier to say “I’m sorry?” Ann Intern Med 2008;149 (11) 811- 816PubMedGoogle ScholarCrossref 14. Safe practices for better healthcare—2009 update. National Quality Forum Web site. http://www.qualityforum.org/Publications/2009/03/Safe_Practices_for_Better_Healthcare–2009_Update.aspx. Accessed August 22, 2009Google Scholar 15. Gallagher TH A 62-year-old woman with skin cancer who experienced wrong-site surgery. JAMA 2009;302 (6) 669- 677PubMedGoogle ScholarCrossref 16. Newman-Toker DEPronovost PJ Diagnostic errors—the next frontier for patient safety. JAMA 2009;301 (10) 1060- 1062PubMedGoogle ScholarCrossref 17. Graber M Diagnostic error in medicine: a case of neglect. Jt Comm J Qual Patient Saf 2005;31 (2) 106- 113PubMedGoogle Scholar 18. Chandra ANundy SSeabury SA The growth of physician medical malpractice payments: evidence from the National Practitioner Data Bank. Health Aff (Millwood) 2005; ((suppl Web exclusives)) W5-240- W5-249PubMedGoogle Scholar 19. Shojania KGBurton ECMcDonald KMGoldman L Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA 2003;289 (21) 2849- 2856PubMedGoogle ScholarCrossref 20. Graber MLFranklin NGordon RR Diagnostic error in internal medicine. Arch Intern Med 2005;165 (13) 1493- 1499PubMedGoogle ScholarCrossref 21. Croskerry P Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med 2003;41 (1) 110- 120PubMedGoogle ScholarCrossref 22. Croskerry P The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003;78 (8) 775- 780PubMedGoogle ScholarCrossref 23. Redelmeier DA Improving patient care: the cognitive psychology of missed diagnoses. Ann Intern Med 2005;142 (2) 115- 120PubMedGoogle ScholarCrossref 24. Kravet SJHowell EWright SM Morbidity and mortality conference, grand rounds, and the ACGME's core competencies. J Gen Intern Med 2006;21 (11) 1192- 1194PubMedGoogle ScholarCrossref 25. Morbidity & mortality rounds on the Web AHRQ WebM&M Web site. http://webmm.ahrq.gov. Accessed August 22, 2009Google Scholar

Journal

Archives of Internal Medicine – American Medical Association

Published: Nov 9, 2009

Keywords: quality of care,disclosure,patient safety,adverse event

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