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Emergency Medicine News:
doi: 10.1097/01.EEM.0000388460.37572.df
Living with the LLSA

Living with the LLSA: Disclosing Medical Errors and the Cosmetic Outcome of Pediatric Lacerations

Diaz, Jorge A. MD

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Author Information

Author Credentials and Financial Disclosure: Dr. Diaz is an Assistant Clinical Professor of Medicine at the David Geffen School of Medicine at the University of California at Los Angeles, and the Director of Urgent Care at Olive View-UCLA Medical Center. All faculty and staff in a position to control the content of this CME activity have disclosed that they and their spouses/life partners (if any) have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity.

Learning Objectives: After completing this CME activity, the physician should be better able to:

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1. Apply the basic concepts for disclosing medical errors to patients.

2. Demonstrate the key elements of disclosing unanticipated outcomes to patients.

3. Compare the use of absorbable sutures with nonabsorbable sutures for pediatric wound repair.

Articles from the 2010 LLSA Reading List

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Disclosing Harmful Medical Errors to Patients

Gallagher TH, et al

N Engl J Med

2007;356(26):2713

Multiple studies report a high prevalence of harmful medical errors. Despite efforts to decrease their occurrence, some amount of error is unavoidable. Patients expect to be informed when a harmful medical error occurs, but physicians are hesitant to disclose them because of the potential for liability risk. Although many physicians endorse the idea of error disclosure, most don't practice it, and those that do are often poorly trained. After reading this article, emergency physicians should be better able to apply the basic concepts for the disclosure of medical errors to patients, demonstrate the key elements of disclosing unanticipated outcomes to patients, and compare the use of absorbable sutures to nonabsorbable sutures for pediatric wound repair.

In 2001, the Joint Commission issued a disclosure standard strongly recommending that patients be informed about all care outcomes, including harmful and unanticipated ones. The standard, however, was vague, and did not specify the content of disclosure or that patients be told that an error occurred, but it did link the disclosure requirement to hospital accreditation, bringing national attention to the topic. By 2005, 69 percent of health care organizations had established disclosure policies.

The most obvious method of error disclosure is to have the patient's physician have a basic conversation about the unanticipated outcome. But to be effective, physicians need training or coaching on how to handle these difficult situations. Another form of disclosure, commonly used in hospitals, is for a risk manager to disclose the event. Yet another model involves developing a rapid response team that specializes in error disclosure.

Physicians can be insecure about disclosing medical errors. They may feel uncomfortable about offering an apology that might constitute legal admission of responsibility. Most states and government initiatives, however, do not consider disclosure of an error an admission of legal responsibility or liability.

The National Quality Forum (NQF) offers a list of key elements for safely disclosing unanticipated outcomes to patients that includes providing facts about the event, expressing regret for any unanticipated outcome, and offering a formal apology. There are also several prominent disclosure programs, such as the COPIC 3Rs program (www.callcopic.com), which include other key elements such as disclosure being linked to no-fault compensation, disclosure coaching and training for physicians, and case management. Many hospitals also voluntarily participate in the Leapfrog Group, which publishes disclosure compliance data on the Internet.

Several disclosure programs report a significant reduction in the cost and frequency of litigation since implementation of the programs. Making generalizations about the impact on liability is difficult, however, because of the limited scope of these efforts and the lack of rigorous testing. The implementation of disclosure policies is inevitable. Physicians are becoming more open to disclosing unanticipated events and errors to patients. Initial data suggest that admitting to an error does not increase the risk of litigation.

Comment: Medical errors became an important national issue with the publication of the 2000 Institute of Medicine report, To Err is Human. (Washington, D.C.: National Academy Press, 2000; Synopsis: http://bit.ly/IOMerr.) ACEP then developed a new policy in 2003 titled Disclosure of Medical Errors, which directs emergency physicians to inform the patient promptly about an error and its consequences. (www.acep.org/practres.aspx?id=29178.)

In addition to disclosure, the patient should be informed that an investigation will be undertaken to prevent similar events in the future and that the charges incurred, whenever possible, will be cancelled or mitigated. A thorough explanation of what will be done medically to correct the harm or minimize its consequences should be conveyed to the patient.

At the county hospital where I work, the risk management department takes a proactive approach by contacting the patient whenever a bad or unanticipated outcome occurs. Patients are offered monetary compensation, an apology, and support without admitting fault. The Los Angeles County Health system is self-insured, and they claim marked decreases in losses and legal costs since implementation of this approach.

A Randomized Controlled Trial Comparing Long-Term Cosmetic Outcomes of Traumatic Pediatric Lacerations Repaired with Absorbable Plain Gut Versus Non Absorbable Nylon Suture

Karounis H, et al

Acad Emergency Med

2004;11(7):730

This elegant randomized clinical trial sought to show that the use of absorbable sutures in pediatric traumatic lacerations provides good long-term cosmesis without an increase in complications (infections, dehiscence rate, and need for surgical scar revision) when compared with traditional nonabsorbable sutures.

In traditional teaching, nonabsorbable sutures are often recommended as the material of choice for closing the outer skin layer. Many surgeons have challenged this notion recently, recommending that pediatric lacerations requiring sutures should be repaired instead using absorbable sutures, except when lacerations are over areas of high tension. Unfortunately, most of these small, uncontrolled, or retrospective studies have been done with operative wounds rather than traumatic lacerations. Absorbable sutures afford the major advantage of not requiring a return visit for suture removal. Obviously, this is of great benefit to the patient, and can represent major cost savings to the health care system.

This study analyzed the outcome of 95 pediatric emergency department patients. The primary outcome was a previously validated visual analog scale of cosmesis (VAS) performed by a plastic surgeon four months after repair. The secondary outcome was a wound evaluation score (WES) that was previously validated. Scores on each scale were similar in both groups.

This study suggests that plain gut absorbable suture material in the repair of pediatric traumatic laceration results in similar long-term cosmesis and complication rates as traumatic wounds repaired with nonabsorbable nylon suture material. A limitation of the study was that it involved only pediatric patients. Additionally, only plain gut suture was used in the absorbable suture group. There are many rapidly absorbing suture materials now available that may provide different cosmetic results.

Comment: The ideal method of laceration closure is relatively painless, minimally traumatic, and rapid. It provides good cosmetic results, has low rates of wound complications, and does not require routine follow-up care. Tissue adhesives fit this profile well, but unfortunately cannot be used for many laceration repairs.

Available literature seems to point to no significant difference in long-term cosmetic outcomes based on the choice of suture material. One study of facial lacerations randomly assigned patients for wound closure with either absorbable or nonabsorbable sutures, and compared wound and scar formation for six months. No significant differences in cosmetic outcomes were found. (Arch Facial Plastic Surg 2003;5[6]:488.) Another study followed facial wound outcomes for nine to 12 months after repair, and found no significant cosmetic differences from the use of either absorbable sutures, nonabsorbable sutures, or tissue adhesives. (Am J Emerg Med 2004; 22[4]:254.)

For the past 15 years, I have been using absorbable sutures almost exclusively for laceration repair in adults and children. Plastic surgeons and ENT physicians in my community support their use, and report acceptable long-term cosmetic results. In addition to minimizing time lost from work or school and the inconvenience and cost of a return visit, absorbable sutures are particularly helpful in the pediatric population because they can eliminate further anxiety related to suture removal. Although this study was limited to children, there is no good reason why the results should not apply to adults.

Click and Connect! Access the links in this article by reading it on www.EM-News.com.

Luis M. Lovato, MD, an Associate Professor at the David Geffen School of Medicine at UCLA, the Director of Critical Care in the Department of Emergency Medicine at Olive View-UCLA Medical Center, and an instructor for the National MegaLLSA Review Course (www.megallsa.com), serves as the medical editor of this column.

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CME Participation Instructions

To earn CME credit, you must read the article in Emergency Medicine News, and complete the evaluation questions and quiz, answering at least 80 percent of the questions correctly. Mail the completed quiz with your check for $12 payable to Lippincott Continuing Medical Education Institute, Inc., Two Commerce Square, 2001 Market St., Third Fl., Philadelphia, PA 19103. Only the first entry will be considered for credit, and must be received by Lippincott Continuing Medical Education Institute by September 30, 2011. Acknowledgment will be sent to you within six to eight weeks of participation.

Lippincott Continuing Medical Education Institute is accredited by the Accreditation Council for Continuing Medical Education to provide medical education to physicians. Lippincott Continuing Medical Education Institute designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit.™ Physicians should only claim credit commensurate with the extent of their participation in the activities.

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