Managing Medical Error Disclosure - Term Paper Example

Managing Medical Error Disclosure This paper deals with medical error disclosure by health care professionals using the four frameworks of structural, human resources, political and symbolic as concepts propounded by Bolman and Deal. Medical errors are both inevitable as well as avoidable as they occur due to systemic flaws and human errors due to cognitive failure or sheer negligence. The frameworks serve as powerful tools in understanding the organisational situation and help reorganise or reframing as the authors state, the organisation to prevent future occurrences of medical errors and handling disclosure of medical errors. Introduction Incidence of medical errors has been on the increase (Mazor et al 2006). Medical errors are also called euphemistically as adverse events. A report titled “To Err is Human” had talked about frequency of medical error about a decade ago (Levinson, 2009). In spite of high incidence of serious medical errors, there had been no guidelines from professional bodies as to how to deal with medical errors until a few years ago (Bratton, 2007). Disclosing medical error to the patient has been high on the agenda of ethical practitioners in the medical profession contrary to what time and again insurance companies and their attorneys have advised against disclosure (Guadagnino, 2005). Medical error is the fifth leading cause of death in the U.S. and the Institute of Medicine (IOM) has estimated the related costs at $ 29 billion (Rajendran, 2001). Medical errors are not necessarily related to an individual’s negligence. It can be due to systemic deficiencies (Howe, 2000). Problem statement Medical errors are so rampant that they are now considered a public health issue endangering safety of patients. Medical error had been recognized as early as in mid 1950s. But there had been no change in medical practice until recent times aimed at avoiding them. For example, in the case of tonsillectomy debated for the past more than two decades as an unnecessary procedure , it was only after the public scandal involving death of children during early 1970, that the medical profession woke up to the realty (Millenson, 2002). There are more than one million adverse events which end up in 44,000 to 98,000 patient deaths in the U.S. (Basanta, 2003).However much the efforts are being taken to avoid medical errors, it has not been possible to totally eradicate them as they are now daily routine to be confronted with by the health industry as whole at some place or other. Hence, in order to put the patients and their relatives at ease, the policy makers have made it equally mandatory for the service providers to disclose such medical errors to the patients instead of hiding them as had been in the past. However, it is not as simple as it sounds since disclosure of medical errors impacts upon the credibility of the physicians as well as the hospitals. Frames of reference Hospitals are not alone in encountering adverse events resulting in deaths or injuries. In fact, hospital administrators are benefited from non-medical sectors who experience similar adverse events. The non-medical sectors are aviation, nuclear power and armed forces. They experience adverse events due to human errors and systems failures. Health sector is a highly complex and dynamic and it is bound to experience medical errors. Aviation industry has found that faulty team work has been responsible for accidents and experts are trying to improve crew performance and by applying concepts adopted by the aviation industry, health care sector is improving team work and thereby proving that medical errors are preventable (Barach, 2003). A study reported in The Lancet reveals that 52 % of errors examined i.e 78 out of 149 are attributable to wrong diagnosis. In these cases, the slips and lapses occurred in spite of well intended acts. Wrong diagnosis is not taken kindly by the system as it is attributable to cognitive process arising out of lack of knowledge, inexperience and short cuts for want of facilities (Dunn, Reddy and Bowes, 2005). The error disclosure obligation being voluntary ethically, medical practitioners and the hospital administration they belong can tackle the situation by following the concepts arsing out of what is called reframing organisations propounded by Bolman and Deal (2005). As mentioned earlier that organisational flaws are mostly responsible for occurrence of errors, the authors suggest certain frames of reference “to identify what is wrong in the organizations and what can be done to correct it” (Stadtlander, 2007, p1). They are four frames of reference under which analysis of an organization’s wrongs and correction of them can be undertaken. They are characterized by the authors as Structural Frame, Human Resource Frame, Political Frame and Symbolic Frame (Bolman and Deal, 2003). Each of these frames is discussed in the following pages. The authors equate frames to concepts metaphorically referred to as “windows, maps, tools, lenses, orientations, and perspectives” (Chapter 1, p 12). The term “frame” just helps one carry in one’s mind the ideas behind their labels such as structural, political etc. STRUCTURAL This deals with organisation of groups and teams for obtaining results. Structure of an organisation determines its (organisational) behaviour. The assumption is behaviour will be rational. The role assignment to people in the organisation is key to goal achievement. For example nursing in a hospital undergoes structural changes aimed at better patient care delivery. The structural transformation is from functional care delivery to team care delivery to modular care delivery. With this, nurse-physician communication becomes secondary when nursing function gets restructured at the unit level for better efficiency. (Arford, 2005). This is what Bolman and Deal (2003) refers to structural frame encompassing goals, specialised roles and relationships on formal basis. This frame is useful to reorganise or restructure groups or teams for obtaining results in alignment with organisation environment and technology. Hence in the event of medical errors caused by systemic flaws, efforts could be aimed at structural changes resulting in role changes among the people concerned to prevent future occurrence of similar medical errors. The IOM has already gone on record that majority of medical errors are systemic and that remedy lies in systems improvement rather than finding fault with individuals. The FDA has found that time-constrained health care system has been responsible for the incidence of avoidable medical errors causing loss of billion of dollars besides loss of lives. The Institute for Health Care Improvement shares the same concern attributing medical errors to complexity of health care. Donald M. Barwick of the institute recommends standardisation and simplification through use of bar-codes by which patients get their right doses of the right medications. Further more, insufficient history of patient without the information on their allergies, medicines they are already on, absence of previous medical history and lab results are also the causes of medical errors (Vozikis, 2009). Thus, structural framework involves laying down of blue print for a pattern of expected outcomes and procedures and providing stable environments which are ‘hierarchies and rule oriented” (Bolman and Deal, No date). The theme of this paper being management of medical error disclosure, the structural reframing of the organisation helps disclose medical errors without the hierarchies or divisions remaining water-tight compartments. HUMAN RESOURCE This frame deals with how organisation must be tailored to take care of human needs, enhance human resource management and to have interpersonal and group dynamics in a positive manner. Under this frame, the authors refer to family as the metaphor for organization, needs, skills, to relationship as central concepts, to image of leadership as empowerment and basic leadership challenge as alignment of organizational needs with that of human (Chapter 1, p 16).Herzberg, Mausner and Synderman (1959), Alderfer (1972) Hackman and Oldham (1980) and Maslow and Kaplan (1998) have all already identified human needs and motivation as part of theories of organizational behaviour. Hackman and Oldham (1980) went further by designing a job characteristics model incorporating five elements namely (1) Skill variety, (2) task identity, (3) task significance, (4) autonomy, and (5) feedback. If jobs in organisations are designed incorporating these characteristics, the employees will find their jobs meaningful and assume responsibility for their performance. This is as a result of motivation, good quality of work and highest possible job satisfaction. The needs hierarchy of Maslow and other theories of motivation form the basis of job-enrichment strategies in health care institutions. Arford (2005) points out that this framing is focussed on development rather than evaluation which structural perspective deals with. Developments underlines the need to invest in hospital staff for a continuous development of employees as leaders, managers etc. The employees thereby attain the ideal competency and gain autonomy in their jobs. Competency refers to development of clinical, coordination and interpersonal skills. The human resources of an organisation prevent incidence of avoidable medical errors through negligence and management of disclosure of medical errors becomes easier in an organisation where workers are highly motivated and well paid. Their self-esteem and self-pride would motivate them to disclose medical errors to the patients without hesitation and without fear of reprisal. POLITICAL This shows how power struggle within organisation should be tackled by coping with power and conflict, forming coalitions, developing political skills and dealing with internal and external politics. Individuals in organisation vie with each other for power and recognition just as people do in society. The political frame or perspective is based on the fact that the organizational behaviour is driven by the competition for scarce resources which include status, control, wealth and power or influence. Pfeffer (1992) says that organisations unlike structuralists, are not rational and they are goal-centred and dynamic capable of transformation at the will of those in charge. As conflicts in organisations are constant, Thomas (1975) advocates strategies for conflict management such as “competing, collaborating, compromising, avoiding and accommodating” (Thomas, 1975). Competing against an aggressor is justified as the competition at its height can lead to centrality of the problem. Collaboration among potential competing entities avoids conflict in an organisation, ultimate aim of which being value of solution though collaboration is greater than aggregate of the individual values. Similarly, compromising, avoiding and accommodating result in ideal conflict resolution depending upon the situation. In a hospital setting where line managers and staff managers work, there is huge potential for conflict which ultimately impacts up on the patient care delivery likely to result in medical errors. Doing what is in the best interest of the patient is often the defence adopted for conflict resolution. However, medical error disclosure under political perspective requires political will on the part of risk managers. Schultz, Mitchell, Massey and Fieldsted (2006), caution that competition for authority though viewed with negativity is far better than absence of it which will be devastating to an organisation. Medical error disclosure under this perspective requires resolute managers to face the reality in their struggle for power and recognition. The least damage that disclosure would cause rather than by not disclosing, should be a motivating factor for risk managers under this perspective. SYMBOLIC This frame work tells the reader how culture is shaped for a meaningful purpose and work in the organisation and how to foster team spirit through rituals and ceremonies and stories. Also called cultural perspective, this symbolic framework is to understand why people conduct themselves in a particular fashion. Shein (1985; 1999) and Zwell (2000), the cultural theorists posit that an organisation is shaped by particular culture with unique and distinctive features. The culture is driven by shared beliefs and values by the individuals in the organisation. If autonomy is believed to be achieved by obeying orders, the individuals would do so. On the other hand, if the belief is that it can be achieved only by higher education, then individuals would go for it. Likewise, professions are also governed by a set of beliefs and cultures. Thus, medicine and nursing being different professions and therefore having different culture, there is bound to cultural diversity within the same organisation where they have to work together. This cultural diversity is a source of strength for the entity within the context of patient care. The medical errors can be best avoided if the nursing professionals adopt interaction with physicians in such a manner that messages are kept brief, factual and action oriented. Therefore, the urgency of patient care prompts them to avoid describing messages in any other context (Arford, 2005). Disclosure of medical error to patient is therefore driven by both cultural diversity as well as by shared values. However, culture does play a crucial role in the manner in which a medical error is likely to be disclosed. Overall comments about frames of reference analysis. “The multiple frames of work enable organisations’ leaders to decode organisational complexity. Examples of eBay, Enron, Harley Davidson, the New York Fire Department and the U.S. Marine Corps detailed by the authors as case examples show how the above frames can be used as tools for reframing organisational situations” (Bolman and Deal, 2003). Medical error prevention management as well as medical error disclosure through the above mentioned four perspectives. The structural, human resources, political and symbolic frames are useful in understanding the organisational behaviour and the medical error management as well as its disclosure become easy by proper understanding of the issues involved. The four frames of references help understand how the risk managers perceive their respective health care institutions. In a recent study by Susan J and Mathieu (2010) it was found that all the four cognitive lenses known as frames had been used by 14 out of 16 sixteen respondents who were faculties of medicine. The human resource perspective was favoured by all the participants for obvious reasons of advantages of motivation. Similarly, fourteen out of sixteen participants favoured political and symbolic perspectives. Structural perspective was favoured only by three participants. Though the study was within the medical education context, the study helps appreciate the utility of Bolman and Deal typology even today. The four perspectives of Bolman and Deal are the powerful tools to analyse an organisation’s attitude towards patients’ safety. The structural perspective looks for the formal roles and relationships among the organisation. If there is a mismatch between the structure and the medical error or disclosure situation, a reorganisation is called for. The human resource perspective helps improve organisations’ ability to motivate their employees so that they get maximum benefit from their human resources. The political frame deals with the inevitable conflict between resources and power within the organisation. Admitting that conflict is inherent as people are bound to interact with one another in any organisation, solutions for problems faced can be obtained by learning how to avail of the available resources and using political traits such as bargaining, negotiation and compromise. Symbolic frame is said to be an often neglected one in an organisational change process. It provides employees with values and meaning of their jobs beyond their remuneration (Hemman, 2002). Possible solution based on analysis Development of organisational policy as regards disclosure of medical error is foremost important since it will prompt staff to disclose medical error. Communication of the harm done should be made at the appropriate time, right location and environment. Health care professionals should be educated how to disclose a medical error. Although who ever causes the error should be involved in the disclosure, he or she should do so in the presence of experienced personnel as part of the team. There should be no delay in disclosure when detected. Delay will result in negative events which can not be controlled. The most convenient place is where it is most suitable for the patient and family. It is the bedside, if at the hospital but privacy must be ensured. Disclosure must be truthful and at the same time must address the feeling, facts and concerns whenever and wherever appropriate (Hemman, 2002). Conclusion The medical error disclosure is a painful process for both the service provider as well as to the patient. Disclosure of error can prompt an otherwise ignorant patient or family to initiate penal action against the wrong-doer and the institution. Conversely, it can also pacify an otherwise aggressive patient or family to drop any penal action proposed. It can also mitigate the negative consequences which would otherwise be disastrous in the absence of a disclosure. The culture of disclosure which is voluntary should only result in reduction epidemiology of medical errors and possible pardon by the patient or family. An open apology besides disclosure should be patent without the fear that it will be used as evidence against the service provider. References Alderfer, C.P. (1972). Existence, relatedness, and growth: Human needs in organizational settings. New York: Free Press in Arford Patricia, H. (2005) Nursing Econ, 23 (2): 72-77 Retrieved October 6, 2010 . Arford Patricia, H. (2005) Nursing Econ, 23 (2): 72-77 Retrieved October 6, 2010 . Barach Paul (2003). The End of the Beginning. Lessons Learned from the Patient Safety Movement. The Journal of Legal Medicine, 24: -27. Basanta W.Eugene (2003). Changing the culture of patient safety and medical errors. A symposium introduction and overview. 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