Analysis of Medical Errors - Research Paper Example

Analysis of Medical Errors To err is human according to the great medieval poet Alexander Pope while to have our medical needs fully treated by machines is not yet feasibly possible. Machines are not capable of understanding abstract and highly individualized concepts such as pain, suffering, discomfort, the possibility of false triggers or non-localized pain caused by psychological issues compounded on top of physical anomalies. It requires a human to understand these processes and a human is, as we are all aware, entirely capable of making mistakes. Although mistakes are made every day in hospitals across the country during the regular course of treating patients, there has been a long debate regarding whether or not patients are actually informed of these mistakes and what procedures are followed in making sure patients are aware of the mistakes that have been made. The issue is heavily laden with emotional and fiscal burden as patients must be aware of their treatment progress and any mistakes that have been made while hospitals and doctors have a very real need to protect themselves from lawsuits and protect their credibility. At the same time, it is difficult for many doctors to have to face the fact that in the course of attempting to improve health, they may have inadvertently made it worse and then to try to communicate this failing to the patients who have trusted them. While it seems the greatest opinion among medical workers is that patients should be informed whenever mistakes have been made, the reality is that the medical profession has a large tendency to hide mistakes when possible so as to avoid unpleasantness. The purpose of the current research is to discover what the prevailing opinion is among doctors and healthcare organizations regarding the revelation of mistakes made, how these opinions differ and what is recommended in terms of making these disclosures to the patient. In “Disclosing Medical Errors to Patients,”1 the authors point out the prevalence of avoidable error or ‘adverse events’ within the medical profession as being relatively high – 37 percent of the discovered cases in a Canadian study preventable. In response to this, “leaders in the patient-safety movement have called for the system defects that underlie most errors to be corrected, as well as improvement in the recognition and reporting of errors and the disclosure of harmful errors to patients and their families.”2 Benefits of full disclosure are outlined, such as patients having greater knowledge about their own treatment and thus able to make more informed decisions and patients’ ability to participate in problem-solving techniques to prevent future errors from occurring again. However, the article also points out the difficulty doctors have had in providing full disclosure. Comparing the attitudes of doctors in the U.S. and Canada, where malpractice laws are largely different, the authors indicate that there are few differences in the disclosure practices on either side of the border, suggesting that the threat of lawsuits is not the most significant barrier to disclosure practices, but that institutions and insurers sometimes are. To try to offset the threat of malpractice lawsuits in the face of full discloser, the authors highlight a number of states and organizations, such as the Veterans Affairs Medical Center, in which medical errors are compensated through the organization without the need for patients to go through lengthy legal proceedings. While this technique may be effective in reducing the number of malpractice lawsuits as patients are adequately compensated and treated for the effects of the medical mistake, the authors also acknowledge that there is a vast difference in the layman’s concept of full disclosure and the physician’s. Solutions for these problems are offered in the form of training sessions for doctors and full-time fully-trained support staff to assist with full disclosure whenever the need arises. The first question to ask in this kind of research is what do the patients themselves wish for. According to Wilson and McCaffrey, “as many as 98,000 hospitalized Americans die each year as a result of medical errors.”3 These statistics are both surprising and alarming to many people and begin to suggest the profound number of people who are directly affected by medical errors as cases of injury, as opposed to death, are likely much higher. As is demonstrated throughout the subsequent literature review, American patients have overwhelmingly indicated that they believe they are due full disclosure regarding medical mistakes that lead to any form of harm. One study determined that 98 percent of study participants wanted full disclosure regardless of the severity of the error or the seriousness of the outcome. Another study identified the information patients expected from their health care providers when errors were made. These included information regarding all harmful errors, how and why the errors occurred, how these types of errors will be avoided in the future and an apology from the medical staff responsible.4 In the same study, healthcare providers indicated they also felt disclosure was important, but they placed less emphasis on making the connections regarding the error for the patients, instead requiring them to make the necessary connections on their own. The researchers conclude that patients have a very strong desire for full disclosure of medical errors and that they understand the depth to which this can affect their treatment. Not only do they gain greater understanding of the specific problems they are experiencing in order to make more informed decisions regarding their treatment plans, but patients are able to gain a greater degree of trust in their physicians, realizing that they are going to be honest with them. Patients are also aware that full disclosure would facilitate the relationship between doctor and patient so that more effective treatment plans might be discovered to deal with any adverse affects of medical errors. While many doctors and nurses report feeling it is important for patients to know when mistakes had been made, not all of these medical professionals are aware just how to go about making this information available to patients or what risks they run in facing potential lawsuits and other issues. The problem of revealing medical error is more than simply the human tendency not to want to admit when one is wrong. One study conducted to discover just what these difficulties are discovered that there are several contributing factors to doctors’ unwillingness to fully disclose medical error which range from concern and fear for the self to uncertainty and concern that accurate and complete information is available and will not damage their relationship with the patient or the institution.5 To discover some of the difficulties as they actually exist in the field, Kaldijan6 surveyed a number of doctors and nurses in the Midwest, Mid-Atlantic and Northeast regions of the United States to discover their actual practices when mistakes occur. The study was formatted as a cross-sectional survey that built upon previous work and encompassed a range of faculty physicians, practicing resident physicians and medical students. The survey requested information from the respondent regarding whether they had ever made a mistake in treatment that either prolonged treatment or that caused discomfort, disability or death and whether or how they had communicated this mistake to the patient or family. It also provided a sample scenario in which a mistake had been made and asked for the respondent’s opinions regarding disclosure to the patient or family based on whether the outcome had been no harm, minor harm or major harm. The survey concluded with a question regarding malpractice lawsuits. Nearly half of all respondents indicated that they had committed a minor or major mistake in the practice of medicine, but that reporting these errors to the patient was always questionable. Sometimes they did and sometimes they didn’t while one respondent indicated that he was instructed not to reveal the mistake on the advice of a medical attorney. “Most notable among our findings is the observation that, although more than 90 percent of our respondents reported that they would likely disclose a hypothetical error resulting in minor or major harm to a patient, only 41 percent of faculty and resident physicians had ever disclosed an actual minor error and only five percent had ever disclosed an actual major error.”7 The primary concern for these physicians in making this decision of whether to disclose or not seems to have been based primarily upon a fear of lawsuits. One difficulty in attempting to determine issues of disclosure is in defining what is meant by the term to start. Patients indicate they want full disclosure of all medical errors while practical experience informs physicians that only those mistakes that may cause harm should be addressed to any significant detail. A study conducted by Fein (et al)8 was designed to obtain a clear perception of patient expectations regarding disclosure and compare them to the ideas and practices of the medical profession. The study was conducted through the hosting of several focus groups of medical administrators and physicians with the express purpose being to stimulate open communication regarding attitudes and actual practices regarding disclosure of medical mistakes. In conducting the study, medical error was specifically defined as “a commission or omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were negative consequences.”9 Focus groups were given a scenario and then asked to discuss issues of disclosure, whether it should be provided, how physicians might approach the issue and what administrators might expect to hear. Results of the study indicate that patients generally expect six elements of disclosure: admission of the mistake, discussion of the event, understandable link drawn between mistake and effects, discussion of the effects, understandable link to potential or real harm, and communication regarding the harm caused. “Most clinicians indicated that they would disclose an error to patients, but the qualitative analysis revealed that clinicians held a nuanced definition of ‘disclosure’ that most often did not contain the elements desired by patients.”10 The study concluded that physicians and patients generally had different ideas in mind when considering disclosure to patients and that one effective means of reducing this communication gap would be by defining the term disclosure in more specific terms. These conclusions were largely supported by the findings of another study conducted by Gallagher.11 A great deal of the fear physicians feel regarding full disclosure about medical error, as has been discovered, is the fear of medical malpractice lawsuits. As a result of this fear, they are often found to be reluctant to communicate in clear terms with patients and their families although studies have indicated that they are willing to disclose medical errors within the system itself as a means of reducing future risk.12 A study by Mazor (et al)13 sought to discover whether full disclosure coupled with positive physician-patient relationships, responsibility for any associated costs and the severity of the effects of the mistake had any effect upon the patient’s likelihood to sue. The study was conducted by showing a random sample of a Health Maintenance Organization’s members who had volunteered for the study one of 16 videos that were produced regarding a medical error. Each of these videos was designed to test one or more of the four factors that might have an impact on a patient’s likelihood to sue – full disclosure, positive patient-physician relationship, waiving medical costs associated with the error and severity of the effects of the error. Contrary to actual practice, this study demonstrated that full disclosure of medical errors was more likely to either have no effect at all upon a patient’s likely response or to reap positive benefits between doctor and patient rather than negative ones. Because of the admission of error, patients are paradoxically more likely to trust their physicians and less likely to switch doctors. “Studies have found that patients and family members pursuing legal action subsequent to an error are often motivated by the desire for explanations and apologies.”14 The idea that the lawsuits were generally not about the money seems to be supported in the finding that the offer of providing medical care for the effects of the error without further cost to the patient generally had a negative effect on the situation. However, these responses were always contingent upon the severity of the effects of the error. The greater the severity, the more likely the patient or the patient’s family would switch doctors and seek legal advice. However, in making the move toward full disclosure on a level that is understandable and expected by the patient, other researchers urge caution and more detailed study. Studdert (et al), for example, points out that no studies have yet been conducted that examine full disclosure’s tendency to deter lawsuits as compared to full disclosure’s ability to incite lawsuits.15 The researchers point out that “the vast majority of patients who sustain medical injury never sue, which creates a huge reservoir of potential claims”16 while sociologists suggest that these people don’t sue because they don’t realize the connection between medical error and the problems they are experiencing. To test the theory that full disclosure would lead to greater numbers of lawsuits rather than less, the researchers developed a survey based on previous research and data that was then given to experts loosely defined as “people whom we recognized from their publications or professional experience as having relevant experience”17 to assess patients’ probability to sue or not to sue based upon full disclosure of medical mistakes. “The experts predicted that among patients who experienced severe injury as a result of negligence, disclosure would on average deter 32 percent from suing and prompt claims by 31 percent of patients who would not otherwise have sued.”18 Only when the injuries were not the result of medical negligence did full disclosure have a significant impact on the numbers of lawsuits, with an estimated 57 percent of patients likely to be deterred from suing by full disclosure as compared to an estimated 17 percent being induced to sue as a result.19 The model they developed from this study indicated that the number of payments as a result of lawsuits would increase rather than decrease as a result of full disclosure practices, particularly in more severe cases or in cases caused by medical negligence. Although the researchers are not attempting to suggest that full disclosure practices not be followed, they explicitly state within their study the ethical and moral importance of full disclosure for the patient, they urge researchers to take a more realistic look at the number of medical error cases that are unrecognized by the patient. With a clearer understanding of the issues from the patient’s point of view as well as the physician’s point of view, it is also necessary to consider the more pragmatic legal questions involved in the concept of full disclosure. According to one attorney, the best policy continues in keeping with our traditional adage – honesty is the best policy. Winslade and McKinney suggest several reasons why disclosure, as early and completely as possible, is necessary and recommended from a legal standpoint.20 The first reason for this is to protect other medical practitioners who might have been involved in the same procedure, such as in the example of a surgery in which a number of people are responsible for the patient’s well-being, but only one person is necessary to cause the surgery to go wrong. Another reason for immediate reporting is to indicate areas in which more safety precautions might be implemented in order to prevent similar mistakes from happening in the future. Thirdly, it is the physician’s professional ethical code that he or she be responsible for their activities and to acknowledge the results of their actions for good or ill. “We further suggest that the ethical health lawyer’s advice go beyond recommending truthful disclosure to include recommending a sincere apology and an appropriate acceptance of responsibility.”21 More than simply acknowledging responsibility, Winslade and McKinney indicate that physicians should approach the issue head-on rather than adopting defensive or avoidance strategies and, when deemed appropriate, to have grief counselors in attendance to help the family cope with the news.22 In the end, full disclosure is considered, even within the legal profession, as an ethical responsibility on the part of the medical staff as well as a financially and professionally responsible approach to business. In considering the question of full disclosure when medical mistakes occur, it becomes clear that there are a number of elements involved on numerous planes of existence. Medical mistakes occur on a daily basis in hospitals and clinics across the country, more often than any would like to admit leading to the death of the patient. Patients have overwhelmingly made it clear that they both expect and desire their medical providers to give them all of the information regarding any medical mistakes that might have occurred in their treatment regardless of the degree of harm caused and that they need this information to be clear and straightforward. When treated with respect and compassion, given all of the available information, they have proven less likely to seek legal retribution and more likely to remain with their present physician, having developed a stronger level of trust. This is contingent upon the degree of medical error and the severity of its effects. However, physicians and medical institutions have largely adopted a policy of partial disclosure in such a way so as to make patients believe they will be provided with full disclosure but confusing the issue by taking an apologetic or avoidance approach to the issue. This approach is illustrated by the doctors themselves as they indicate that they expect the patients to make the necessary connections between the mistakes and the harmful effects the mistakes have had. While some caution is warned regarding expectations that medical lawsuits will be decreased as a result of more sincere full disclosure of medical mistakes, attorneys continue to suggest that this is the only proper policy for physicians to take in their medical practice. References Fein, Stephanie P.; Lee H. Hilborne; Eugene M. Spiritus; Gregory B. Seymann; Craig R. Keenan; Kaveh G. Shojania; Marjorie Kagawa-Singer; Neil S. Wenger. (2007). “The Many Faces of Error Disclosure: A Common Set of Elements and a Definition.” Society of General Internal Medicine. Vol. 22: 755-761. Gallagher, Thomas H.; Amy D. Waterman; Alison G. Ebers; Victoria J. Fraser; & Wendy Levinson. (2003). “Patients’ and Physicians’ Attitudes Regarding the Disclosure of Medical Errors.” Journal of the American Medical Association. Vol. 289, N. 8: 1001-1007. Garbutt, Jane; Amy D. Waterman; Julie M. Kapp; William Claiborne Dunagan; Wendy Levinson; Victoria Fraser; & Thomas H. Gallagher. (2008). “Lost Opportunities: How Physicians Communicate About Medical Errors: Physicians’ dissatisfaction with existing error-reporting systems could lead them to share such information with their colleagues but not with their hospital.” Health Affairs. Vol. 27, N. 1: 246-255. Kaldjian, Lauris C.; Elizabeth W. Jones; Gary E. Rosenthal; Toni Tripp-Reimer; & Stephen L. Hills. (September 2006). “An Empirically Derived Taxonomy of Factors Affecting Physicians’ Willingness to Disclose Medical Errors.” Journal of General Internal Medicine. Vol. 21, N. 9: 942-948. Kaldijan, Lauris C.; Elizabeth W. Jones; Barry J. Wu; Valerie L. Forman-Hoffman; Benjamin H. Levi; & Gary E. Rosenthal. (2007). “Disclosing Medical Errors to Patients: Attitudes and Practices of Physicians and Trainees.” Journal of General Internal Medicine. Vol. 22: 988-996. Levinson, Wendy & Thomas H. Gallagher. (July 31, 2007). “Disclosing Medical Errors to Patients: A Status Report.” Candian Medical Association Journal. Vol. 177, N. 3: 265-267. Mazor, Kathleen M.; George W. Reed; Robert A. Yood; Melissa A. Fischer; Joann Baril; & Jerry H. Gurwitz. (2006). “Disclosure of Medical Errors.” Journal of General Internal Medicine. Vol. 21: 704-710. Studdert, David M.; Michelle M. Mello; Atul A. Gawande; Troyen A. Brennan; & Y. Claire Wang. (2007). “Disclosure of Medical Injury to Patients: An Improbably Risk Management Strategy.” Health Affairs. Vol. 26, N. 1: 215-226. Wilson, Juliana & Ruth McCaffrey. (October 2005). “Disclosure of Medical Errors to Patients.” Medsurg Nursing. Vol. 14, N. 5: 319. Winslade, William & E. Bernadette McKinney. (Winter 2006). “To Tell or Not to Tell: Disclosing Medical Error.” Nanotechnology. 813-816. Read More