During an operation years ago to repair a damaged tendon in a photographer’s dominant hand, a member of the University of Michigan Health System (UMHS) surgical team accidentally cut the patient’s median nerve, causing a potentially disabling injury.
Rather than circling the wagons and going into deny-and-defend mode, University Hospital staff quickly informed the patient, apologized, and recommended an immediate nerve graft.
“We cut a check for $200,000, no questions asked, right after his nerve graft was done, because the dumbest thing in the world would have been to allow his photography business to fall apart,” recalls Rick Boothman, UMHS’s chief risk officer. The photographer hired a helper for his business and eventually regained some thumb function; he never sued, and the system reached a final settlement with him.
Similar scenarios have played out multiple times since 2001, when Boothman and the UMHS risk management team pioneered a model for handling medical errors and improving patient safety that is built on openness with patients and families and includes:
- Early reporting and analysis of adverse events
- Full explanations for patients and families
- Emotional support for health care professionals involved in the mishap
- Apologies and compensation to patients when the hospital is at fault
This nondefensive approach to addressing medical errors is gaining ground. “We are seeing unprecedented adoption by health care institutions and by liability insurers of what [are] called communication and resolution programs, or CRPs,” says Thomas H. Gallagher, MD, professor and associate chair for patient care quality, safety, and value at the University of Washington (UW) School of Medicine.
The CRP approach fits with hospitals’ core clinical mission, Boothman says. They can’t have a trusting patient relationship “and then cut and run when a patient gets harmed. More importantly, confronting these issues openly and honestly is critical to building a culture that encourages continual clinical improvement.”
Counterintuitive but effective
While the open approach may feel counterintuitive to administrators, physicians, and malpractice attorneys, studies and anecdotal accounts suggest transparency and accountability policies can save hospitals, patients, and families years of grueling litigation that typically ends in settlement.
“It is really a culture change for an organization to move away from this notion that if something goes wrong that the best thing to do is just be quiet about it.”
Thomas H. Gallagher, MD
University of Washington School of Medicine
“These programs have demonstrated that effective communication with patients and families in the immediate aftermath of patient harm, regardless of the cause of that harm, can lead to organizational learning, improved surrogate measures of patient safety, and reduction in medical liability,” researchers noted in a 2016 Health Services Research study, citing previous literature on the topic.
The authors found that a CRP at the University of Illinois Hospital and Health Sciences System (UIH) nearly doubled the number of incident reports, halved the number of claims, and lowered legal costs and settlement amounts, among other expenses.
After UMHS started fully disclosing and compensating for medical errors, researchers found a decrease in liability claims and lawsuits, lower liability costs, and shorter time to resolution, according to a study published in the August 2010 Annals of Internal Medicine.
“It is really a culture change for an organization to move away from this notion that if something goes wrong that the best thing to do is just be quiet about it,” says Gallagher, who is also executive director of the Collaborative for Accountability and Improvement, a national network housed at the UW Medical Center that is aimed at accelerating CRP implementation.
Gallagher estimates that more than 200 U.S. health care organizations adopted CRPs in 2017 alone and expects a majority of institutions will have such programs in the next two or three years.
A safety culture
The CRP model saves money in malpractice costs, but the primary goal is to build accountability and a culture focused on improved patient safety, says Boothman. When hospitals defend indiscriminately against both legitimate and illegitimate patient claims, he says, “How can they learn and improve patient safety?”
The movement toward a safety culture has been an enormous change, says Robert D. Truog, MD, director of Harvard Medical School’s Center for Bioethics. Truog also is a coauthor of Talking with Patients and Families about Medical Error: A Guide for Education and Practice, a Boston Children’s Hospital intensive care physician, and a professor of medical ethics, anesthesiology, and pediatrics.
Decades ago, physicians didn’t give much thought to medical errors, Truog explains. “We were all doing our best and that was the end of it,” he says. Then, a milestone 2000 Institute of Medicine report, To Err Is Human: Building a Safer Health System, called medical errors a major cause of preventable deaths and recommended that hospitals focus on improving patient safety. Today, the medical community recognizes medical errors as a leading cause of death and disability.
“Confronting these issues openly and honestly is critical to building a culture that encourages continual clinical improvement.”
Rick Boothman
University of Michigan Health System
The federal Agency for Healthcare Research and Quality released the Communication and Optimal Resolution (CANDOR) Toolkit in 2016 to help hospitals set up programs for responding to unexpected patient harm in an open, constructive way.
Boothman and David B. Mayer, MD, are among those whose work influenced the CANDOR Toolkit. Mayer helped to develop the CRP at the UIH years ago. Now vice president of quality and safety at MedStar Health, Mayer established a patient safety immersion camp for medical students and residents operated by MedStar’s Institute for Quality and Safety in several cities.
MedStar Health, which runs 10 hospitals in Maryland and the District of Columbia, including Georgetown University Hospital, also has trained people from more than 200 other hospitals through its quality and safety institute’s Center for Open, Honest Communication.
Teaching physicians to disclose and resolve
In 2006, Harvard’s teaching hospitals adopted a policy on responding to medical errors. About 500 of the hospitals’ senior leaders underwent training, then trained doctors and nurses at their facilities to coach peers in disclosing medical errors to patients and families and then apologizing for the mistake.
“These are very difficult conversations to have, there are a lot of pitfalls,” Truog says, noting that patients and families want to hear from providers involved in an event, not high-level hospital officials. “Full disclosure and apology is the right thing to do. It just needs to be done well.”
For the past decade, Harvard medical students have practiced these tough conversations in role-playing exercises with actors. Truog coaches physicians and nurses to be careful with their words and to show support but not take blame if they don’t know yet what went wrong. “In the case of an error, yes, an apology is always called for,” Truog says; if the cause is unclear, clinicians might say, “I’m sorry this has happened to you.”
CRPs also aim to alleviate the guilt and shame that physicians and nurses often feel after making a medical error. Keeping mistakes quiet is a human impulse, and trainees may be especially concerned about how disclosure might affect their evaluations, Gallagher says. “Educators need to really work on ensuring that they have a nonpunitive culture so that trainees know that what is expected of them is this openness, and that their evaluations won’t suffer as a result of [reporting an error],” Gallagher says.
Truog describes a recent meeting in which a young trainee physician, blaming herself for a mistake, received assurances that the error hadn’t been hers alone—that systems had allowed it to happen. “I thought it was handled extremely well,” he says. “I could see there was a transition in her feelings about it, from feeling very shameful to feeling supported.”
It is important to learn from any adverse medical incident and improve, Mayer stresses. Making a serious medical error can be devastating for clinicians, too, and has even led to physician suicides, he says. “This isn’t a shame and blame game. These people [who have made unintentional mistakes] need hugs more than anything.”
Boothman concurs, and says the open communication process at the University of Michigan has become a recruiting tool. While it is common practice in training residents today, he still gets grateful feedback. “I thought I’d mention that Michigan’s medical error policy was a big part of my choosing to come to residency here,” one resident wrote to him. “I’m sure I’m not alone.”