Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation

Advancements in defensive medicine research: Based on current literature

To investigate and comprehend the evolving research hotspots, cutting-edge trends, and frontiers associated with defensive medicine. The original data was collected from the Web of Science core collection and then subjected to a preliminary retrieval process. Following screening, a total of 654 relevant documents met the criteria and underwent subsequent statistical analysis. Software CiteSpace was employed for conducting a customized visual analysis on the number of articles, keywords, research institutions, and authors associated with defensive medicine. The defensive medicine research network was primarily established in Western countries, particularly the United States, and its findings and conceptual framework have significantly influenced defensive medicine research in other regions. Currently, quantitative methods dominated most studies while qualitative surveys remained limited. Defensive medicine research mainly focused on high-risk medical specialties such as surgery and obstetrics. Research on defensive medicine pertained to the core characteristics of its conceptual framework. An in-depth investigation into the factors that give rise to defensive medicine is required, along with the generation of more generalizable research findings to provide valuable insights for improving and intervening in defensive medicine.

Patient and Family Involvement in Serious Incident Investigations From the Perspectives of Key Stakeholders: A Review of the Qualitative Evidence

OBJECTIVES

Investigations of healthcare harm often overlook the valuable insights of patients and families. Our review aimed to explore the perspectives of key stakeholders when patients and families were involved in serious incident investigations.

METHODS

The authors searched three databases (Medline, PsycInfo, and CINAHL) and Connected Papers software for qualitative studies in which patients and families were involved in serious incident investigations until no new articles were found.

RESULTS

Twenty-seven papers were eligible. The perspectives of patients and families, healthcare professionals, nonclinical staff, and legal staff were sought across acute, mental health and maternity settings. Most patients and families valued being involved; however, it was important that investigations were flexible and sensitive to both clinical and emotional aspects of care to avoid compounding harm. This included the following: early active listening with empathy for trauma, sincere and timely apology, fostering trust and transparency, making realistic timelines clear, and establishing effective nonadversarial communication. Most staff perceived that patient and family involvement could improve investigation quality, promote an open culture, and help ensure future safety. However, it was made difficult when multidisciplinary input was absent, workload and staff turnover were high, training and support needs were unmet, and fears surrounded litigation. Potential solutions included enhancing the clarity of roles and responsibilities, adequately training staff, and providing long and short-term support to stakeholders.

CONCLUSIONS

Our review provides insights to ensure patient and family involvement in serious incident investigations considers both clinical and emotional aspects of care, is meaningful for all key stakeholders, and avoids compounding harm. However, significant gaps in the literature remain.

Perception of the Disclosure of Adverse Events in a Latin American Culture: A National Survey

Introduction

Adverse events are common and are responsible for a significant burden in the healthcare setting. Such issues can vary according to the local culture and relevant policies. The current literature on the subject primarily addresses Anglo-Saxon cultures; this study focused on understanding the perception of disclosure in a middle-income country in Latin America.

Methods

In this descriptive study conducted from June-August, 2021, an online self-administered survey about disclosure practice used a convenience sample of 995 Brazilian healthcare professionals.

Results

Based on two different outcomes presented following a hypothetical adverse event (outcome 1: death; outcome 2: no permanent damage), 77.9% of participants fully agree that disclosure should be performed in both scenarios. Although 67.1% claimed that disclosure changes the perception of the institution by those involved, only 8.3% fully agree that there would be a reduction in trust regarding the institution. Despite only 11.5% of participants fully agreeing that disclosure increases the chance of legal action against professionals and institutions, 92.7% fully or partially agree that judicialization was possible in scenario 1, and 72.4% agree it was possible in scenario 2. Of the participants, 64.2% claimed they already faced a "disclosure" situation, and 44.3% fully believe that the person directly involved in the adverse event should participate in the disclosure.

Conclusion

In this sample of professionals from a middle-income country in Latin America, the practice of disclosure was considered ethical, and the majority of respondents affirmed that it should always be performed. Nonetheless, this call for transparency collides with participants' perception of a higher risk of legal action when disclosure is performed after a negative outcome situation.

How will state medical boards handle cases involving disclosure and apology for medical errors?

Surveys were sent to 68 American state medical boards, including territories of the United States, inquiring how they handle—or will handle—cases involving disclosure and apology after medical errors. Surveys were not sent to specialty boards. Thirty-eight state medical boards ( n  =  38, 56%) responded to the survey, with 31 completing the survey (46% completion rate) and seven boards ( n  =  7) providing explanations for nonparticipation and other thoughts; 30 boards did not respond in any manner. Boards that completed the survey indicated that disclosure and apology and other positive post-event behavior by physicians are likely to be viewed favorably and disclosing physicians will not be easy targets for disciplinary measures, though boards also stressed they view each case on the merits and patient safety is their top priority. Recommendations are made for policy makers and other stakeholders.

"It Matters What I Think, Not What You Say": Scientific Evidence for a Medical Error Disclosure Competence (MEDC) Model

OBJECTIVE

This study sought to validate the ability of a "Medical Error Disclosure Competence" (MEDC) model to predict the effects of physicians' communication skills on error disclosure outcomes in a simulated context.

METHOD

A random sample of 721 respondents was assigned to 16 experimental disclosure conditions that tested the MEDC model's constructs across 2 severity conditions (i.e., minor error and sentinel event).

RESULTS

Severity did not affect survey respondents' perceptions of the physician's disclosure style. Respondents who viewed the nonverbally skilled disclosure perceived the disclosure as more adequate compared to respondents in the "low nonverbal skill" disclosure condition. Interpersonal adaptability did not affect respondents' adequacy ratings. Consistent with the MEDC model, those who viewed the physician's error disclosure as inadequate indicated that they would be more prone to engage in relational distancing behaviors, while those who rated the disclosure as adequate were more likely to reinvest into their relationship with their physician. These respondents also had higher resilience scores. In the context of a sentinel event, perceived adequacy significantly predicted endorsing legal redress or remedies (e.g., lawsuit). Verbal apology (e.g., "I'm sorry," "I apologize") did not predict any significant variance in the model beyond the physician's nonverbal skill.

CONCLUSION

In a simulated disclosure setting, physicians' communicative skills-particularly effective nonverbal communication during a disclosure-trigger outcomes that affect the patient, the physician, and the provider-patient relationship. Findings from this study suggest that MEDC guidelines may be helpful in reducing financial and reputational risks to individual providers and institutions, particularly in the context of a sentinel event.

A Transactional "Second-Victim" Model-Experiences of Affected Healthcare Professionals in Acute-Somatic Inpatient Settings: A Qualitative Metasynthesis

BACKGROUND

"Second victims" are healthcare professionals traumatized by involvement in significant adverse events. Associated burdens, e.g., guilt, can impair professional performance, thereby endangering patient safety. To date, however, a model of second victims' experiences toward a deeper understanding of qualitative studies is missing. Therefore, we aimed to identify, describe, and interpret these experiences in acute-somatic inpatient settings.

METHODS

This qualitative metasynthesis reflects a systematic literature search of PubMed, CINAHL, and PsycINFO, extended by hand searches and expert consultations. Two researchers independently evaluated qualitative studies in German and English, assessing study quality via internationally approved criteria. Results were analyzed inductively and aggregated quantitatively.

RESULTS

Based on 19 qualitative studies (explorative-descriptive: n = 13; grounded theory: n = 3; phenomenology: n = 3), a model of second-victim experience was drafted. This depicts a multistage developmental process: in appraising their situation, second victims focus on their involvement in an adverse event, and they become traumatized. To restore their integrity, they attempt to understand the event and to act accordingly; however, their reactions are commonly emotional and issue focused. Outcomes include leaving the profession, surviving, or thriving. This development process is alternately modulated by safety culture and healthcare professionals.

CONCLUSIONS

For the first time, this model works systematically from the second-victim perspective based on qualitative studies. Based on our findings, we recommend integrating second victims' experiences into safety culture and root-cause analyses. Our transactional model of second-victim experience provides a foundation for strategies to maintain and improve patient safety.

Honesty and Transparency, Indispensable to the Clinical Mission-Part II: How Communication and Resolution Programs Promote Patient Safety and Trust

When patients are harmed by health care, concerns fan out in all directions. Patients and families confront a sea of uncertainty, contending with injuries that drain them physically, emotionally, and financially. Health care professionals experience a powerful mix of emotions, but are seldom afforded the time to process what happened or the resources to relieve suffering and prevent harm. Honesty, transparency, and empathy are indispensable to a comprehensive approach that prioritizes patient and family-centered response to unintended harm, clinical improvement, and redemptive peer review. Part 2 introduces the second of three pillars for advancing the clinical mission: communication and transparency.

How U.S. teams advanced communication and resolution program adoption at local, state and national levels

Widespread adoption of evidence-based new healthcare practice guidelines can take years to occur. Policy leaders frequently make decisions based on incomplete and often incorrect information. These policy decisions can result in wasteful healthcare spending and poor health outcomes. Proponents of a medicolegal policy, Communication-and-Resolution Program (CRP), were successful in their endeavor to get hospitals to implement CRP, state legislators to pass state laws to encourage CRP adoption by hospitals, and national medical societies to endorse CRP to their members. The purpose of this paper is to explain the methods used by nine teams in their efforts to accomplish these goals. We identify reasons for the successes, failures, and obstacles faced by the teams in their effort to advance CRP. Our hope is to educate groups on a potentially more expeditious method to advance evidence-based policy than other methods. We propose that advocates of an innovation determine the concerns and goals of all stakeholder groups impacted by the policy. The specific concerns of each group should be the focus of the message to that group. Teams should identify the opinion leaders of each stakeholder group who can champion the new policy to their peers. Teams can aid the opinion leaders in their communication efforts to their peer group. National groups should be organized to help teams in their endeavor to advance evidence-based policies.

Bridging the Gap Between Ethics and Practice

This article attempts to bridge the gap between widely discussed ethical principles of Human-centered AI (HCAI) and practical steps for effective governance. Since HCAI systems are developed and implemented in multiple organizational structures, I propose 15 recommendations at three levels of governance: team, organization, and industry. The recommendations are intended to increase the reliability, safety, and trustworthiness of HCAI systems: (1) reliable systems based on sound software engineering practices, (2) safety culture through business management strategies, and (3) trustworthy certification by independent oversight. Software engineering practices within teams include audit trails to enable analysis of failures, software engineering workflows, verification and validation testing, bias testing to enhance fairness, and explainable user interfaces. The safety culture within organizations comes from management strategies that include leadership commitment to safety, hiring and training oriented to safety, extensive reporting of failures and near misses, internal review boards for problems and future plans, and alignment with industry standard practices. The trustworthiness certification comes from industry-wide efforts that include government interventions and regulation, accounting firms conducting external audits, insurance companies compensating for failures, non-governmental and civil society organizations advancing design principles, and professional organizations and research institutes developing standards, policies, and novel ideas. The larger goal of effective governance is to limit the dangers and increase the benefits of HCAI to individuals, organizations, and society.

Ensuring successful implementation of communication-and-resolution programmes

BACKGROUND

Communication-and-resolution programmes (CRP) aim to increase transparency surrounding adverse events, improve patient safety and promote reconciliation by proactively meeting injured patients' needs. Although early adopters of CRP models reported relatively smooth implementation, other organisations have struggled to achieve the same. However, two Massachusetts hospital systems implementing a CRP demonstrated high fidelity to protocol without raising liability costs.

STUDY QUESTION

What factors may account for the Massachusetts hospitals' ability to implement their CRP successfully?

SETTING

The CRP was collaboratively designed by two academic medical centres, four of their community hospitals and a multistakeholder coalition.

DATA AND METHODS

Data were synthesised from (1) key informant interviews around the time of implementation and 2 years later with individuals important to the CRP's success and (2) notes from 89 teleconferences between hospitals' CRP implementation teams and study staff to discuss implementation progress. Interview transcripts and teleconference notes were analysed using standard methods of thematic content analysis. A total of 45 individuals participated in interviews (n=24 persons in 38 interviews), teleconferences (n=32) or both (n=11).

RESULTS

Participants identified facilitators of the hospitals' success as: (1) the support of top institutional leaders, (2) heavy investments in educating physicians about the programme, (3) active cultivation of the relationship between hospital risk managers and representatives from the liability insurer, (4) the use of formal decision protocols, (5) effective oversight by full-time project managers, (6) collaborative group implementation, and (7) small institutional size.

CONCLUSION

Although not necessarily causal, several distinctive factors appear to be associated with successful CRP implementation.

Review of disclosure and apology literature: Gaps and needs

A review of the literature related to the disclosure movement was conducted to find gaps and needs while identifying areas where needs are being met. There are several articles that address claims and other economic factors. Moreover, there are many papers that define barriers to disclosure with suggested workarounds. There is also a wealth of training content that teaches how to say "sorry." However, gaps and needs were identified. The "gap list" was developed with a focus on concepts that are novel or not mentioned in the literature as well as issues in the disclosure movement that would benefit from greater attention: (1) lack of research and disclosure training content for health care professionals beyond acute care; (2) messaging and disclosure programs, including the meaning of "apology"; (3) insufficient integration between disclosure programs and second victim support programs; (4) confidentiality clauses; (5) the National Practitioner Data Bank and state licensure boards being viewed as an impediment to disclosure; (6) understanding awareness of the disclosure movement by consumers, personal injury bar, and payors; (7) measuring what medical and nursing schools are teaching about disclosure; and (8) encouraging states to pass apology laws that support the development of disclosure programs.

Characteristics of Paid Malpractice Claims Among Resident Physicians From 2001 to 2015 in the United States

PURPOSE

Limited information exists about medical malpractice claims against physicians-in-training. Data on residents' involvement in malpractice actions may inform perceptions about medicolegal liability and influence clinical decision-making at a formative stage. This study aimed to characterize rates and payment amounts of paid malpractice claims on behalf of resident physicians in the United States.

METHOD

Using data from the National Practitioner Data Bank, 1,248 paid malpractice claims against resident physicians (interns, residents, and fellows) from 2001 to 2015, representing 1,632,471 residents-years, were analyzed. Temporal trends in overall and specialty-specific paid claim rates, payment amounts, catastrophic (> $1 million) and small (< $100,000) payments, and other claim characteristics were assessed. Payment amounts were compared with attending physicians during the same time period.

RESULTS

The overall paid malpractice claim rate was 0.76 per 1,000 resident-years from 2001 to 2015. Among 1,194 unique residents with paid claims, 95.7% had exactly 1 claim, while 4.3% had 2-4 claims during training. Specialty-specific paid claim rates ranged from 0.12 per 1,000 resident-years (pathology) to 2.96 (obstetrics and gynecology). Overall paid claim rates decreased by 52% from 2001-2005 to 2011-2015 (95% confidence interval [CI]: 0.45, 0.59). Median inflation-adjusted payment amount was $199,024 (2015 dollars), not significantly different from payments made on behalf of attending physicians during the same period. Proportions of catastrophic (11.2%) and small (33.1%) claims did not significantly change over the study period.

CONCLUSIONS

From 2001 to 2015, paid malpractice claim rates on behalf of resident physicians decreased by 52%, while median payment amounts were stable. Resident paid claim rates were lower than attending physicians, while payment amounts were similar.

Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey

Background

How openly healthcare providers communicate after a medical error may influence long-term impacts. We sought to understand whether greater open communication is associated with fewer persisting emotional impacts, healthcare avoidance and loss of trust.

Methods

Cross-sectional 2018 recontact survey assessing experience with medical error in a 2017 random digit dial survey of Massachusetts residents. Two hundred and fifty-three respondents self-reported medical error. Respondents were similar to non-respondents in sociodemographics confirming minimal response bias. Time since error was categorised as <1, 1–2 or 3–6 years before interview. Open communication was measured with six questions assessing different communication elements. Persistent impacts included emotional (eg, sadness, anger), healthcare avoidance (specific providers or all medical care) and loss of trust in healthcare. Logistic regressions examined the association between open communication and long-term impacts.

Results

Of respondents self-reporting a medical error 3–6 years ago, 51% reported at least one current emotional impact; 57% reported avoiding doctor/facilities involved in error; 67% reported loss of trust. Open communication varied: 34% reported no communication and 24% reported ≥5 elements. Controlling for error severity, respondents reporting the most open communication had significantly lower odds of persisting sadness (OR=0.17, 95% CI 0.05 to 0.60, p=0.006), depression (OR=0.16, 95% CI 0.03 to 0.77, p=0.022) or feeling abandoned/betrayed (OR=0.10, 95% CI 0.02 to 0.48, p=0.004) compared with respondents reporting no communication. Open communication significantly predicted less doctor/facility avoidance, but was not associated with medical care avoidance or healthcare trust.

Conclusions

Negative emotional impacts from medical error can persist for years. Open communication is associated with reduced emotional impacts and decreased avoidance of doctors/facilities involved in the error. Communication and resolution programmes could facilitate transparent conversations and reduce some of the negative impacts of medical error.

Do Written Disclosures of Serious Events Increase Risk of Malpractice Claims? One Health Care System's Experience

Supplemental digital content is available in the text.

Objective

This study aimed to determine whether Pennsylvania ACT 13 of 2002 (Mcare) requiring the written and verbal disclosure of “serious events” was accompanied by increased malpractice claims or compensation costs in a large U.S. health system.

Main Outcomes and Measures

The primary outcome was the rate of malpractice claims. The secondary outcome was the amount paid for compensation of malpractice claims. The analyses tested the relationship between the rate of serious event disclosures and the outcome variables, adjusted for the year of the event, category of claim, and the degree of “harm” related to the event.

Results

There were 15,028 serious event disclosures and 1302 total malpractice claims among 1,587,842 patients admitted to UPMC hospitals from May 17, 2002, to June 30, 2011. As the number of serious event disclosures increased, the number of malpractice claims per 1000 admissions remained between 0.62 and 1.03. Based on a matched analysis of claims that were disclosed and those that were not (195 pairs), disclosure status was significantly associated with increased claim payout (disclosures had 2.71 times the payout; 95% confidence interval, 1.56–4.72). Claims with higher harm levels H and I were independently associated with higher payouts than claims with lower harm levels A to D (11.15 times the payout; 95% confidence interval, 2.30–54.07).

Conclusions and Relevance

Implementation of a mandated serious event disclosure law in Pennsylvania was not associated with an overall increase in malpractice claims filed. Among events of similar degree of harm, disclosed events had higher compensation paid compared with those that had not been disclosed.

Audio-video recording during laparoscopic surgery reduces irrelevant conversation between surgeons: a cohort study

Background

The prevalence of perioperative surgical complications is a worldwide issue: In many cases, these events are preventable. Audio-video recording during laparoscopic surgery provides useful information for the purposes of education and event analyses, and may have an impact on the focus of the surgeons operating. The aim of the present study was to investigate how audio-video recording in the operating room during laparoscopic surgery affects the focus of the surgeon and his/her assistant.

Methods

A group of laparoscopic procedures where video recording only was performed was compared to a group where both audio and video recordings were made. All laparoscopic procedures were performed at Lindesberg Hospital, Sweden, during the period August to September 2017. The primary outcome was conversation not relevant to the ongoing procedure. Secondary outcomes were intra- and postoperative adverse events or complications, operation time and number of times the assistant was corrected by the surgeon.

Results

The study included 41 procedures, 20 in the video only group and 21 in the audio-video group. The material comprised laparoscopic cholecystectomies, totally extraperitoneal inguinal hernia repairs and bariatric surgical procedures. Irrelevant conversation time fell from 4.2% of surgical time to 1.4% when both audio and video recordings were made (p = 0.002). No differences in perioperative adverse event or complication rates were seen.

Conclusion

Audio-video recording during laparoscopic abdominal surgery reduces irrelevant conversation time and may improve intraoperative safety and surgical outcome.

Trial registration

Available at FOU Sweden (ID: 232771) and retrospectively at Clinical trials.gov (ID: NCT03425175; date of registration 7/2 2018).

A Multi-Stakeholder Consensus-Driven Research Agenda for Better Understanding and Supporting the Emotional Impact of Harmful Events on Patients and Families

BACKGROUND

The nature and consequences of patient and family emotional harm stemming from preventable medical error, such as losing a loved one or surviving serious medical injury, is poorly understood. Patients and families, clinicians, social scientists, lawyers, and foundation/policy leaders were brought together to establish research priorities for this issue.

METHODS

A one-day conference of diverse stakeholder groups to establish a consensus-driven research agenda focused on (1) priorities for research on the short-term and long-term emotional impact of harmful events on patients and families, (2) barriers and enablers to conducting such research, and (3) actionable steps toward better supporting harmed patients and families now.

RESULTS

Stakeholders discussed patient and family experiences after serious harmful events, including profound isolation, psychological distress, damaging aspects of medical culture, health care aversion, and negative effects on communities. Stakeholder groups reached consensus, defining four research priorities: (1) Establish conceptual framework and patient-centered taxonomy of harm and healing; (2) Describe epidemiology of emotional harm; (3) Determine how to make emotional harm and long-term impacts visible to health care organizations and society at large; and (4) Develop and implement best practices for emotional support of patients and families. The group also created a strategy for overcoming research barriers and actionable "Do Now" approaches to improve the patient and family experience while research is ongoing.

CONCLUSION

Emotional and other long-term impacts of harmful events can have profound consequences for patients and families. Stakeholders designed a path forward to inform approaches that better support harmed patients and families, with both immediately actionable and longer-term research strategies.

Implementing communication and resolution programs: Lessons learned from the first 200 hospitals

The Communication and Optimal Resolution toolkit contains implementation guidance for communication and resolution programs that are comprehensive, principled, and systematic approaches to the prevention and response to patient harm that includes the open and honest communication of inappropriate care to patients and families that is coupled with financial compensation and the commitment to future prevention. The toolkit was released by the Agency for Healthcare Research and Quality in May 2016. The authors describe their experiences with implementing communication and resolution programs with all of the components of Communication and Optimal Resolution and other communication and resolution program best practices in over 200 hospitals. Lessons learned include the ability to predict and discover actual barriers to full implementation and strategies for overcoming them are shared. Future considerations for further dissemination and spread are discussed.

Disclosure of Harmful Medical Error to Patients: A Review With Recommendations for Pathologists

Harmful error is an infrequent but serious challenge in the pathology laboratory. Regulatory bodies and advocacy groups have mandated and encouraged disclosure of error to patients. Many pathologists are interested in participating in disclosure of harmful error but are ill-equipped to do so. This review of the literature with recommendations examines the current state of the patient safety movement and error disclosure as it pertains to pathology and provides a practical and explicit guide for pathologists for who, when, and how to disclose harmful pathology error to patients. The authors provide a definition of harmful pathology error, and the rationale and principles behind effective disclosure are discussed. The changing culture of medicine and its effect on pathology is examined including the trend towards increasing transparency and patient engagement. Related topics are addressed including the management of expected adverse events, barriers to disclosure, and additional resources for the implementation of disclosure programs in pathology.

Overtreatment in the United States

BACKGROUND

Overtreatment is a cause of preventable harm and waste in health care. Little is known about clinician perspectives on the problem. In this study, physicians were surveyed on the prevalence, causes, and implications of overtreatment.

METHODS

2,106 physicians from an online community composed of doctors from the American Medical Association (AMA) masterfile participated in a survey. The survey inquired about the extent of overutilization, as well as causes, solutions, and implications for health care. Main outcome measures included: percentage of unnecessary medical care, most commonly cited reasons of overtreatment, potential solutions, and responses regarding association of profit and overtreatment.

FINDINGS

The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures. The most common cited reasons for overtreatment were fear of malpractice (84.7%), patient pressure/request (59.0%), and difficulty accessing medical records (38.2%). Potential solutions identified were training residents on appropriateness criteria (55.2%), easy access to outside health records (52.0%), and more practice guidelines (51.5%). Most respondents (70.8%) believed that physicians are more likely to perform unnecessary procedures when they profit from them. Most respondents believed that de-emphasizing fee-for-service physician compensation would reduce health care utilization and costs.

CONCLUSION

From the physician perspective, overtreatment is common. Efforts to address the problem should consider the causes and solutions offered by physicians.

Overtreatment in the United States

Background

Overtreatment is a cause of preventable harm and waste in health care. Little is known about clinician perspectives on the problem. In this study, physicians were surveyed on the prevalence, causes, and implications of overtreatment.

Methods

2,106 physicians from an online community composed of doctors from the American Medical Association (AMA) masterfile participated in a survey. The survey inquired about the extent of overutilization, as well as causes, solutions, and implications for health care. Main outcome measures included: percentage of unnecessary medical care, most commonly cited reasons of overtreatment, potential solutions, and responses regarding association of profit and overtreatment.

Findings

The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures. The most common cited reasons for overtreatment were fear of malpractice (84.7%), patient pressure/request (59.0%), and difficulty accessing medical records (38.2%). Potential solutions identified were training residents on appropriateness criteria (55.2%), easy access to outside health records (52.0%), and more practice guidelines (51.5%). Most respondents (70.8%) believed that physicians are more likely to perform unnecessary procedures when they profit from them. Most respondents believed that de-emphasizing fee-for-service physician compensation would reduce health care utilization and costs.

Conclusion

From the physician perspective, overtreatment is common. Efforts to address the problem should consider the causes and solutions offered by physicians.

Disclosing Adverse Events to Patients: International Norms and Trends

OBJECTIVES

There is a growing expectation in health systems around the world that patients will be fully informed when adverse events occur. However, current disclosure practices often fall short of this expectation.

METHODS

We reviewed trends in policy and practice in 5 countries with extensive experience with adverse event disclosure: the United States, the United Kingdom, Canada, New Zealand, and Australia.

RESULTS

We identified 5 themes that reflect key challenges to disclosure: (1) the challenge of putting policy into large-scale practice, (2) the conflict between patient safety theory and patient expectations, (3) the conflict between legal privilege for quality improvement and open disclosure, (4) the challenge of aligning open disclosure with liability compensation, and (5) the challenge of measurement related to disclosure.

CONCLUSIONS

Potential solutions include health worker education coupled with incentives to embed policy into practice, better communication about approaches beyond the punitive, legislation that allows both disclosure to patients and quality improvement protection for institutions, apology protection for providers, comprehensive disclosure programs that include patient compensation, delinking of patient compensation from regulatory scrutiny of disclosing physicians, legal and contractual requirements for disclosure, and better measurement of its occurrence and quality. A longer-term solution involves educating the public and health care workers about patient safety.

A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships

BACKGROUND

OpenNotes, a national movement inviting patients to read their clinicians' notes online, may enhance safety through patient-reported documentation errors.

OBJECTIVE

To test an OpenNotes patient reporting tool focused on safety concerns.

METHODS

We invited 6225 patients through a patient portal to provide note feedback in a quality improvement pilot between August 2014 and 2015. A link at the end of the note led to a 9-question survey. Patient Relations personnel vetted responses, shared safety concerns with providers and documented whether changes were made.

RESULTS

2736/6225(44%) of patients read notes; among these, 1 in 12 patients used the tool, submitting 260 reports. Nearly all (96%) respondents reported understanding the note. Patients and care partners documented potential safety concerns in 23% of reports; 2% did not understand the care plan and 21% reported possible mistakes, including medications, existing health problems, something important missing from the note or current symptoms. Among these, 64% were definite or possible safety concerns on clinician review, and 57% of cases confirmed with patients resulted in a change to the record or care. The feedback tool exceeded the reporting rate of our ambulatory online clinician adverse event reporting system several-fold. After a year, 99% of patients and care partners found the tool valuable, 97% wanted it to continue, 98% reported unchanged or improved relationships with their clinician, and none of the providers in the small pilot reported worsening workflow or relationships with patients.

CONCLUSIONS

Patients and care partners reported potential safety concerns in about one-quarter of reports, often resulting in a change to the record or care. Early data from an OpenNotes patient reporting tool may help engage patients as safety partners without apparent negative consequences for clinician workflow or patient-clinician relationships.

Effect of a health system's medical error disclosure program on gastroenterology-related claims rates and costs

OBJECTIVES

In 2001, the University of Michigan Health System (UMHS) implemented a novel medical error disclosure program. This study analyzes the effect of this program on gastroenterology (GI)-related claims and costs.

METHODS

This was a review of claims in the UMHS Risk Management Database (1990-2010), naming a gastroenterologist. Claims were classified according to pre-determined categories. Claims data, including incident date, date of resolution, and total liability dollars, were reviewed. Mean total liability incurred per claim in the pre- and post-implementation eras was compared. Patient encounter data from the Division of Gastroenterology was also reviewed in order to benchmark claims data with changes in clinical volume.

RESULTS

There were 238,911 GI encounters in the pre-implementation era and 411,944 in the post-implementation era. A total of 66 encounters resulted in claims: 38 in the pre-implementation era and 28 in the post-implementation era. Of the total number of claims, 15.2% alleged delay in diagnosis/misdiagnosis, 42.4% related to a procedure, and 42.4% involved improper management, treatment, or monitoring. The reduction in the proportion of encounters resulting in claims was statistically significant (P=0.001), as was the reduction in time to claim resolution (1,000 vs. 460 days) (P<0.0001). There was also a reduction in the mean total liability per claim ($167,309 pre vs. $81,107 post, 95% confidence interval: 33682.5-300936.2 pre vs. 1687.8-160526.7 post).

CONCLUSIONS

Implementation of a novel medical error disclosure program, promoting transparency and quality improvement, not only decreased the number of GI-related claims per patient encounter, but also dramatically shortened the time to claim resolution.

Disclosing medical errors: the view from the USA

BACKGROUND

Disclosure is increasingly seen as a key component of efforts to improve safety, but does not yet reliably occur in all organizations in the U.S.

APPROACH

We describe the experience to date with disclosure in the U.S. and illustrate the issues with specific clinical examples. Both reputational and legal concerns represent substantial barriers. The evidence to date-mostly from single sites - shows that not only is disclosure the right thing to do, it also appears to decrease malpractice risk. We also discuss the related issue of compensation-practices around this vary greatly. Underlying the push for greater disclosure is also the belief that better disclosure results in an improved culture of safety, which in turn may improve the quality and safety of care.

CONCLUSIONS

Providers have an ethical imperative to disclosure error to patients, and the limited available evidence shows that doing so actually decreases malpractice risk. While disclosure is not yet routine practice in the U.S., the approach is clearly gaining momentum. Telling patients what happened is not enough. They also deserve an apology, and if harmed, to be made whole emotionally and financially. Greater disclosure may not only help individual patients, but may also help with improving safety overall.