ARTICLE IN BRIEF
Experts in patient safety and risk management offer advice on what to do when a colleague makes a medical error.
While most physicians would agree they have an ethical duty to inform a patient about another clinician's medical error, many of them struggle with the challenges of this type of disclosure.
A lack of guidance in disclosing others' mistakes elevates practitioners' uncertainty about how to proceed, according to an Oct. 31 report published in The New England Journal of Medicine (NEJM?). “Consequently, patients may be told little about these events, and opportunities to build trust, ensure that learning occurs after errors, and avoid litigation may be lost,” the authors noted.
The report leads with an example particularly relevant to neurologists. Its authors ask readers to place themselves in the position of a young neurologist practicing in a small hospital. The neurologist admits a 55-year-old woman who suffered an embolic stroke and has hypertension and type 2 diabetes mellitus. In the patient's medical records, it appears that her primary care physician — an internist who provides many of this neurologist's referrals — misinterpreted two office-based electrocardiographic (ECG) tests. The neurologist's findings are confirmed when two cardiologists reviewing the ECGs attribute the patient's palpitations to atrial fibrillation.
To compile recommendations beyond the available guidelines for clinicians and institutions about how to convey colleagues' harmful errors to patients, the authors convened a working group of experts in patient safety, medical malpractice insurance and litigation, error disclosure, patient–provider communication, professionalism, bioethics, and health policy.
“For far too long, physicians have thought that being a good colleague means looking away when we think another clinician has made an error involving a patient we are currently caring for,” lead author Thomas H. Gallagher, MD, a professor in the departments of medicine and bioethics and humanities at the University of Washington in Seattle, told Neurology Today.
“While raising the prospect of a potential error with a colleague is intimidating, physicians need to become more comfortable with effective strategies for discussing quality concerns with one another. Otherwise, the profession will fall short of meeting its obligations to share information about errors with patients and to understand how to prevent errors from recurring,” Dr. Gallagher said.
The whole notion of “explore, don't ignore” is based on an assumption that we need to change the cultural disposition in medicine to keep quiet, Dr. Gallagher said. This process of reaching out to colleagues needs to be done thoughtfully and mindful of legal protections, but that does not equate “to keeping quiet,” he continued.
In the NEJM case, the neurologist does indeed make an effort to point out the mistake to the internist. However, the internist “politely disagrees” and says the neurologist is “confused by noise from his old ECG machine.” Then the internist requests that the neurologist transfer the patient to his service.
TAKE-AWAYS FROM THE CASE
This scenario illustrates the complex interactions that may arise in today's health care environment, where services are provided by different groups of clinicians across multiple care settings. Determining what transpired poses a challenge when a physician may have little firsthand knowledge about the incident, and pertinent documentation in the patient's medical record may be limited.
“It's a very enlightening article — very useful for physicians in general and obviously for neurologists as well,” said Anna DePold Hohler, MD, co-chair of the AAN Patient Safety Subcommittee and an associate professor of neurology at Boston University School of Medicine.
“At certain times, we run into cases where there may have been an error or a bad outcome for some reason,” she added. The process of clarifying and perhaps rectifying the situation can be tricky. “We don't want to sacrifice congeniality, but we also want to protect our patients.”
It's important to keep in mind that a more definitive diagnosis may appear to the neurologist examining a patient in the later stages of a disease. “We have in neurology so many of these neurodegenerative disorders that early on, one thing might look like something else,” Dr. Hohler said. For instance, a patient may not have met full criteria for amyotrophic lateral sclerosis when the first physician performed an evaluation.
“There's a saying that the last neurologist to see the patient is always the smartest because they have the benefit of all the past workup and information,” she said. “They're able to then look at things with a wider lens and be able to sometimes come up with solutions and diagnoses that were not necessarily apparent early on when the symptoms were milder or when the workup was incomplete.”
WIDE RANGE OF POTENTIAL ERRORS
As the NEJM report mentions, there is a wide range of potential errors. At one end of the spectrum, clinical decisions fall under the category of “not what I would have done,” but they remain within the standard of care. Meanwhile, at the opposite end, flagrant errors may raise a concern regarding professional competence or proficiency.
“The anecdote provided is a fairly straightforward example of a possible error. There are some errors in medicine that are this seemingly clear-cut,” said Dan Larriviere MD, JD, acting chair of the department of neurology and residency program director at Ochsner Medical Center's Neuroscience Institute in New Orleans. However, he added that in other circumstances, the causative link between the error and best intervention isn't easy to ascertain. Dr. Larriviere, who also serves on the editorial advisory board of Neurology Today, is chair of the AAN Ethics, Law and Humanities Committee.
“How much must the physician investigate before drawing a conclusion? How certain must the physician be before initiating a discussion with the physician who committed the alleged error, or before going to an institutional review committee, relevant professional organization, or state medical society?” Dr. Larriviere questioned.
The skills involved in error disclosure generally aren't taught in medical school or residency programs, but they are necessary to the practice of medicine. “You need to be forthright with patients about what you know,” said Daniel M. Feinberg, MD, an associate professor of clinical neurology and chief medical officer at the Hospital of the University of Pennsylvania Health System. “You should not feel compelled to state things that are not yet understood. You can always follow up with patients and their families with more information later.”
However, when a clinician says to a patient, “we'll get back to you with more information,” it's important to fulfill that expectation. The physician may learn that a device was faulty or that a mistake occurred because of a misunderstanding. If he or she is uncertain about how to explain the situation to a patient, it's best to consult with the hospital's or health system's risk management team, which is typically part of the legal department. Sometimes it may be wise to avoid specifics and simply say, “We'll make sure that this doesn't happen to anyone else,” Dr. Feinberg said.
ADVICE ON RISK MANAGEMENT
Among the experts available to Dr. Feinberg and his colleagues for advice is Mary Ellen Nepps, JD, senior counsel who manages professional liability litigation for the University of Pennsylvania Health System. She also oversees the system's risk and claims management programs.
Although the NEJM report's authors and some neurologists would advise contacting a provider about a perceived error, Nepps cautioned: “Physicians need to understand that those conversations can be subject to discovery in subsequent litigation. That can undermine the very purpose articulated for these conversations in the article, which is to do this informally and not create a situation that will expose the other physician to potential liability.”
Inquiring about an observation in the patient's medical records may be innocuous, but physicians should avoid a debate about whether proper care was rendered or whether an error occurred. Those types of discussions are best handled through a peer-protected forum, so they aren't subject to legal discovery, Nepps said. The forum can facilitate a consensus on providing any necessary disclosure to a patient. She urges physicians to consult an employer's risk management experts “if they have a concern that they need to escalate.”
However, neurologists in private practice may not have the same access to risk management resources within their own organization. In those cases, Nepps suggests contacting your professional liability insurance carrier. These companies often provide support for private practice physicians confronting challenging situations. Another helpful resource would be the chief medical officer at a hospital where a physician has practicing privileges. That officer's role frequently includes responsibility for quality improvement.
In the NEJM example, Nepps said, the neurologist still has an obligation to recommend a cardiology consultation to the patient, even if the internist declines to do so. However, this can be done without invoking mention of the internist's oversight or perceived error, in which untreated atrial fibrillation may have led to the patient's stroke.
“The ideal situation would be for the neurologist and internist to be on the same page, but if that can't be accomplished, it is important from a quality of care and liability standpoint to provide that information to the patient,” she said of the advice going forward.
Marcus Ponce de Leon, MD, a neurologist in clinical practice in Tacoma, WA, said mistakes should not be hidden from patients. “The ultimate reason is for the patient's health,” said Dr. Ponce de Leon, a movement disorders specialist who handles both inpatient and outpatient neurology cases.
“The health care community is obligated to notify patients about medical errors,” he added, while emphasizing that the integrity of a patient-provider relationship may suffer otherwise. “If mistakes are not revealed to the patient, it violates trust. The patient has to believe that a mistake is going to be revealed.”