“Subtracting insult from injury- Disclosure of medical errors” Patients are often in vulnerable physical or psychological states, even with routine procedures. Therefore, when harm from an unexpected event occurs, especially from someone they trust, reactions can be severe and traumatic. A common human response to something going wrong is to ask: ‘What happened?’ A health care provider goes through the same issues after an error and equally powerful emotions are felt, such as shame, humiliation, fear, panic, guilt, anger and self-doubt. In response to this stress, physicians employ several coping mechanisms, including denial and distancing. “Physicians felt upset and guilty about harming the patient, disappointed about failing to practice medicine to their own high standards, fearful about possible lawsuit, and anxious about the error’s repercussions regarding their reputation” (Gallagher, Waterman & Ebers, 2003, p. 1005). This is compounded by fear of litigation, which causes physicians to feel guarded in their dealings with patients following an error. The healthcare professionals who are at the so-called “sharp end” of medical error are called the “Second Victim.” A common perception among physicians is that good doctors don’t make mistakes. Because of this, physicians learn to keep mistakes to themselves rather than risk the judgment of their peers. In fact, the pressure to be perfect is so great that doctors admit they would lie to colleagues or patients to cover up a mistake. Out of concern for liability exposure, some doctors have given up their practices, limited the kinds of procedures they perform, or restricted the types of patients they see. Some patients resort to threatening with lawsuits to get things straightened up. Growing evidence indicates apologies reduce litigation and offer great, though unquantifiable, emotional benefits for patients, families, and health care providers. A trusting relationship between provider and patient is the bedrock of medical care. Following an adverse medical event, patient and provider relationships face their greatest test. The key to success is open patient–provider communication and a true sense of caring. Helping to maintain a patient–provider relationship is an apology, and then personal, repeated attention to the needs of the patients and families. Patients need action taken quickly and confidently by providers. Quick action provides a sense of reassurance in the confusion. This action must be directed at answering the initial patient worries of ‘what happened?’, ‘what is next?’, ‘is this fixable?’ Provider support of the patient must follow quickly and continue as the process unfolds. Learning Objectives: Understanding the principles of Disclosure Understanding provider and patient expectations of error disclosure Understanding risks & benefits of medical error disclosure

1. Presented at the
3rd Middle East Patient Safety Conference
17 – 19 October 2010
Presented by
Krishnan Sankaranarayanan MBA
Senior Officer Patient Safety
Department of Performance Innovation
Tawam Hospital,
Al Ain, UAE.
Disclosure: The presenter has nothing to disclose, nor has any commercial
interest with any of those information's displayed in this presentation.

2. About Tawam
 Tawam Hospital is a 477-bed tertiary care facility
located in Al Ain, Abu Dhabi, and one of the largest
hospitals in the United Arab Emirates.
 In 2006 Tawam Hospital entered a ten year affiliation
with Johns Hopkins Medicine.

3. Subtracting Insult from Injury
 Statement by: JONATHAN R. COHEN
(Assistant Professor, University of Florida)
 Apologies benefit the victim and the wrongdoer:
 The Victim feels acknowledged
 The wrongdoer feels forgiven
Cohen JR. Advising clients to apologize. Southern California Law Review 1999;72:1009–69.

4. Ice- Breaker
 Is there a possibility that the boy’s death could have
been due to a medical error?

5. Medical Error- Definition
 Failure of a planned action to be completed as
intended or use of a wrong plan to achieve an aim.
(Kohn, et al 2000)
 Errors can include problems in practice, products,
procedures, and systems.

6. Disclosure of medical error-
Definition
 “Communication of a health care provider and a
patient, family members, or the patient’s proxy that
acknowledges the occurrence of an error, discusses
what happened, and describes the link between the
error and outcomes in a manner that is meaningful to
the patient.”Fein et al.: Journal of General Internal Medicine, March, 2007: 755-761
 Disclosure of medical error is not a single
conversation; rather, it needs to occur over time, in a
series of conversations. Straumanis, 2007

7. Problem
 Australia: 18,000 annual deaths from Medical errors,
1995.
 U.S: 44- 98,000 Deaths/year (IOM, 1998)
 United Kingdom: 850,000 incidents/year, 2000.
 Canada: Adverse events in 7% of Admissions 9-24,000
deaths/year. 2004.
 Middle East: There are lack of statistical evidence in
this region to showcase patient deaths happening due
to medical error.

8. This is what we see?

10. Medical mistakes cases referred - United Arab Emirates: Saturday, June 10 - 2006
The UAE Ministry of Health has referred 35 complaints from patients alleging mistakes
in their treatment to the Abu Dhabi National Insurance Company, reported Gulf News.
The complaints have been reported by patients and investigated over the past six
months. The cases have been passed to the insurance company in order to handle any
compensation if it is awarded by the courts

11. What happens after a medical error?

12. Physicians Response
 For a physician being involved in an error evokes
emotions such as shame, humiliation, fear, panic,
guilt, anger and self-doubt. (Wu, 1991 & Hilfiker, 1984)
 Physicians employ several coping mechanisms,
including denial and distancing. (Mizrahi, 1984 & Wu, 1993)
 Causes physicians to feel guarded in their dealings
with patients following an error. (Robin, 1998)

13. Physicians Response
 The types of suffering are
 Increased anxiety about the future possibility of errors,
 Loss of confidence in the work they do,
 Some face difficulty sleeping,
 Concern about their reputation as a physician and
 Reduction in their sense of job satisfaction.
 Excellent clinicians may leave the profession prematurely
when involved in a preventable error.
Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt
Comm J Qual Patient Saf 2007;33:467–76.
Rossheim J. To err is human—even for medical workers. Healthcare monster. http://healthcare.monster.ca/8099_en-CA_pf.asp (accessed 21
Jan 2009).

14. Patients Reactions
 A common human response to something going
wrong is to ask: ‘What happened?’
 Patients interpret denial, distancing and withdrawal as
rejection, and they feel angry and betrayed.
 This anger and betrayal, coupled with a sense that the
physician is not being honest, that prompts patients to
file claims. (Hickson, 1992, Witman, 1996 & Hingorani 1999)

15. Medical error: the second victim..
 The term second victim was initially coined by Wu in his
description of the impact of errors on professionals. The
doctor who makes the mistake needs help too.
 In the aftermath of a mistake, it's important the doctor
seek support to deal with the consequences.
Albert W Wu associate professor
School of Hygiene and Public Health and School of Medicine, Johns
Hopkins University, Baltimore, MD
Wu AW (2000). "Medical error: the second victim. The doctor who makes the mistake needs help too". BMJ 320 (7237): 726–7.

16. Is disclosure the right thing to do?
What professional societies say?
 American Medical Association has identified it
as ethical obligation to disclose.
 American college of Physicians in its ethical
manual state that physicians should disclose to
patients information about procedural or
judgment errors.
 American Nurses Association and the
American College of Healthcare Executives
have code of ethics that require professionals to
respect human dignity and conduct professional
activities with honesty.

17. Is disclosure the right thing to do?
What professional societies say? Contd….
 American Society for Healthcare Risk
Management calls for practicing the profession with
honesty and integrity while avoiding unjust harm to
others.
 National Patient Safety Foundation calls for
providers to disclose medical injury to patients.

18. Disclosure helps in not getting sued.
What research says?
 Full disclosure is found to have a moderating effect
on liability and expense payments.
 Research shows:- (Survey)
 24% of patients filed claims because they believed that
the physicians were not totally honest or covering up
important information. (Hickson, 1992)
 39% of patients would not have filed claims if they had
received explanation and an apology. (Vincent 1994)
 Patients were more likely to sue if they learned of a
physician’s error from some other source. (Witman, 1996)

19. Nondisclosure/ Liability Cycle

20. What is the relationship between disclosure
and litigation?
 Failure to disclose leads patients filing claims.
 Disclosure does not lead to litigation and may in fact
curb liability and expense payments.
 Disclosure helps early and amicable settlement.

21. Significant Barrier
 A common perception among physicians is that good
doctors don’t make mistakes.
 Physicians learn to keep mistakes to themselves rather
than risk the judgment of their peers.
 The pressure to be perfect is so great that doctors
admit they would lie to colleagues or patients to cover
up a mistake.
 Out of concern for liability exposure, some doctors
have given up their practices, limited the kinds of
procedures they perform, or restricted the types of
patients they see
Green, M.J., Farber, N.J., and Ubel, P.A. Lying to each other. Archives of Internal Medicine, 2000;160:2317-23.
Mizrahi, T. Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Social Science & Medicine,
1984;19(2):135-46

22. Significant Barrier- Communication
 Communication skills are not routinely taught to
physicians or any healthcare provider.
 In a study 50% of the Physicians said they had never
received any formal training on handling medical
mistakes. (Maithel, 1998)
 In another study physicians agreed disclosure was
required, they questioned their ability to do so. (Sweet, 1997 &
Gray, 1990)

23. Actions
 Directed at answering the initial patient worries of
‘what happened?’, ‘what is next?’, ‘is this fixable?’
 Provider support of the patient must follow quickly
and continue as the process unfolds.
 Disclosure also restore patients trust in the system.

24. How to Say I'm Sorry
 Detailed account of the situation
 Acknowledgement of the hurt or damage done
 Taking responsibility for the situation
 Recognition of your role in the event
 Statement of regret
 Asking for forgiveness
 A promise that it won't happen again
 A form of restitution whenever possible

25. Medical Errors and the Full Disclosure/
Early Offer Movement-Doug Wojcieszak
 Three guiding principles designed to encourage full
disclosure for medical errors with fair, upfront and
early compensation.
1. Compensate quickly and fairly when inappropriate
medical care causes injury;
2. Defend medically appropriate care vigorously;
3. Reduce patient injuries (and therefore claims) by
learning from mistakes.
Quoted in http://www.sorryworks.net/files/CoalitionPowerpointpresenation.ppt #261,8, Goals of the Coalition

26. Tim McDonald-
But ‘I’m sorry’ alone doesn’t work.”
 Disclose and apologize doesn’t mean the hospitals or
doctors say to a patient or family, “Something went
wrong. We’re sorry. Here’s a check. Ciao.”
 It means, or should mean, they say something like,
“You had a bad outcome. We are sorry. We will try to
help you while we investigate what happened. If it was
our fault, we will take financial and moral
responsibility. We will do our best to make sure it
never happens again to anyone else.”
Tim McDonald, a physician and lawyer who is chief safety and risk officer at the University of Illinois health system in Chicago

27. University of Illinois health system
in Chicago
 Patient-family members sit alongside staff on a board
charged with overseeing plans to prevent errors
 Dr. McDonald says that over the past four years, the
number of lawsuits against the center is down 40%
compared to the period between 1999 and 2004, even
though the number of procedures increased 23%
Tim McDonald, a physician and lawyer who is chief safety and risk officer at the University of Illinois health system in Chicago

28. Other Examples
 The University of Michigan's program of full
disclosure and compensation for medical errors
resulted in a decrease in new claims for compensation
(including lawsuits), time to claim resolution and
lower liability costs
A study published Aug. 17 in the Annals of Internal Medicine.

29. Overcoming barriers to error disclosure
 Culture of blame – shift focus to constructive approach
- What lessons can we learn?
- Are there systems/design issues?
- Are there communication issues?
- Are there ethical concerns?
- How can we improve performance?

30. Overcoming barriers to error disclosure
 Institution support
- Establish disclosure support system
 Provide disclosure education
 Ensure disclosure coaching available at all times
 Provide emotional support
(healthcare workers, administration, patients and
families)

31. Overcoming barriers to error disclosure
 Institution support
 Require medical staff to engage in error disclosure
activities
 Integrate disclosure, patient safety and risk
management activities
 Use performance improvement tools to track and
enhance disclosure

32. Overcoming barriers to error disclosure
 Institution support
 Provide language interpreter
 Provide patient-physician liaison
 Provide system of rewarding error reporting
 Provide continuing education on error disclosure
 Provide systems changes to decrease error occurrence

33. Overcoming barriers to error disclosure
 Role of care providers
 Participation in disclosure education and skill training
 Follow guidelines for error reporting
 Utilize resources for error disclosure
 Actively lobby for laws
 Participate in safety and quality improvement activities

34. Overcoming barriers to error disclosure
 Role of care providers
 Prepare before meeting with patient and family (Role
Play and practice)
 Review and know current facts of event
 Be ready for intense emotion
 Have legal representation if patient has one
 Use plain language
 Do not rush conversation (Never say I know how
difficult it is) -
Straumanis, 2007

35. Old proverb till holds good
 “To err is human, to forgive divine” - Alexander
Pope (1688-1744)
 “Justifying a fault doubles it” a French Proverb.

36. How to implement open disclosure
 Establishing a “ Culture of Safety”
 Leadership engagement-”Achieve “buy in” from top,
bottom & sideways”
 Identify potential champions and possible
stakeholders.
 Must create an accounting method for remedies.
 Community involvement and education.
 Identify and establish – “Micro system”- cultural is
local.
 Simulation Training- create standardized patients.
 Celebrating safety- Encourages open reporting.

37. What we have done in Tawam
 Created the Patient Safety dept
 Senior Executive Partnership
 Leadership were trained on Patient Safety
 Rolled out the Johns Hopkins-”Comprehensive Unit-
based Safety Program” (CUSP).
 Implemented “Patient Safety Net" online incident
reporting system.
 Instituted the “Best Catch Award”
 Created a Patient Safety video (Arabic Version-
http://www.youtube.com/watch?v=IkM-V0NIU5U )

38. References:
 Courtney J Wusthoff (2001). Medical mistakes and
disclosure: the role of the medical student. JAMA.
286:1080–1081.
 Gallagher TH, Waterman AD, Ebers AG, Fraser VJ,
Levinson W. (2003). Patients' and doctors' attitudes
regarding the disclosure of medical errors. JAMA. 289:1001–
1007.
 Mazor KM, Simon SR, NGurwitz JH (2004).
Communicating with Patients about Medical Errors - A
Review of the Literature. Arch Intern Med. 164:1690–1697.
 Gert B, Culver CM, Clouser DK (2006) Bioethics: A
Systematic Approach. Oxford: Oxford University Press.

39. References:
 Improving patient safety in hospitals (2002) University of Michigan
Health System Patient Safety Toolkit,
http://www.med.umich.edu/patientsafetytoolkit/ accessed
September 27, 2009.
 Perspective on disclosure of unanticipated outcome information
(2001). American Society for Healthcare Risk Managemet (AHA)
Whitepaper,
www.ashrm.org/ashrm/education/development/monographs/Discl
osure.2001.pdf accessed September 27, 2009.
 Gallagher TH, Content of medical error disclosures (2004), Virtual
Mentor, vol 6 (3), http://virtualmentor.ama-assn.org/2004/03/pfor1-
0403.html accessed September 26, 2009.
 American Medical Association. Code of Medical Ethics of the
American Medical Association: current opinions with annotations
2006-2007ed. Chicago: AMA, 2006.

40. References:
 Department of Veterans Affairs (Veterans Health Administration)
Disclosure of adverse events to patients: VHA Directive 2008-002.
January 18, 2008.
 American College of Obstetrician Gynecologists Committee Opinion
Number 380, Disclosure and discussion of adverse events (2007),
Obstetrics and Gynecology, 2007.
 Massachusetts Coalition for the Prevention of Medical Errors (2006),
When things go wrong: Responding to adverse events A consensus
statement of the Harvard Hospitals, http://www.macoalition.org
accessed September 26, 2009.
 Boothman RC, Blackwell AC, Campbell DA, Commiskey E, Anderson S
(2009). A better approach to medical malpractice claims? The
University of Michigan experience, J Health & Life Sciences Law, vol
2(2), pp. 125-159

41. References:
 The Joint Commission report. “What Did the Doctor Say?:” Improving
Health Literacy to Protect Patient Safety. (2007). Retrieved Sept. 27,
2009, from the Joint Commission
Website: http://www.jointcommission.org/nr/rdonlyres/d5248b2e-
e7e6-4121-8874-99c7b4888301/0/improving_health_literacy.pdf
 Gabriel, Barbara A. (Nov. 2007). The Law: Apology Accepted?: More
physicians are learning to say “I’m sorry” when medical mistakes
happen.
 Retrieved Sept. 27, 2009, from Physicians Practice
Website: http://www.physicianspractice.com/index/fuseaction/articles
.details/articleID/1084/page/1.htm
 AMA Code of Medical Ethics: Opinion 8.121 - Ethical Responsibility to
Study and Prevent Error and Harm (Dec. 2003). Retrieved Sept. 27,
2009, from the American Medical Association Website:
http://www.ama-assn.org/ama/pub/physician-resources/medical-
ethics/code-medical-ethics/opinion8121.shtml

42. References:
 Hickson, G. B., Clayton, E. W., Githens, P. B., et al.
Factors that prompted families to file medical
malpractice claims following perinatal injuries. JAMA,
1992;267:1359-63.
 Witman, A. B., Park, D. M., and Hardin, s. B. How do
patients want physicians to handel mistakes? A survey of
internal medicince patients in an academic setting,
Archives of Internal Medicine, 1996;156(22):2565-69.
 Karaman, S.S., and Hamm, G. Risk management:
honesty may be the best policy. Annals of Internal
Medicine, 1999:131(12):963-67.
 Hickson, 1992.

43. References:
 Vincent, C., Young, M., and Philips, A. Why do people sue
doctors? A study of patients and relatives taking legal
action. Lancet, 1994;343:1609-13.
 Witman, 1996
 Stafford v. Shultz, 42 Cal.2d.
 Kreugar v. St Joseph’s Hospital, 305 N.W.2d 18.
 http://www.perfectapology.com/index.html

44. References:
 Massachusetts Coalition for the Prevention of Medical Errors
(2006), When things go wrong: Responding to adverse events A
consensus statement of the Harvard Hospitals,
http://www.macoalition.org accessed September 26, 2009.
 Perspective on disclosure of unanticipated outcome information
(2001). American Society for Healthcare Risk Managemet (AHA)
Whitepaper,
www.ashrm.org/ashrm/education/development/monographs/Discl
osure.2001.pdf accessed September 27, 2009.
 Improving patient safety in hospitals (2002) University of Michigan
Health System Patient Safety Toolkit,
http://www.med.umich.edu/patientsafetytoolkit/ accessed
September 27, 2009.
 Boothman RC, Blackwell AC, Campbell DA, Commiskey E,
Anderson S (2009). A better approach to medical malpractice
claims? The University of Michigan experience, J Health & Life
Sciences Law, vol 2(2), pp. 125-159.

45. Apologizing Effectively to Patients
and Families
 IHI Open School Video

46. Request
Open disclosure of medical
errors is a sensitive topic
It is quite challenging
Lets make a beginning
Lets start talking about it

47. Patient Safety Top Priority
“Cultural change is both evolutionary and revolutionary”
Thank you