AuntMinnie: What has been the culture in radiology around disclosing harmful errors to patients?
Dr. Stephen Brown, Children's Hospital Boston
Brown: First, I'd like to point out that it's not just radiologists who have a history of reluctance to disclose medical errors -- this is a phenomenon throughout medicine. But many radiologists have traditionally shied away from communicating with patients at all, much less about radiology errors.
Error disclosure is a difficult piece of communication for a group of specialists who have generally not had much training about effective communication with patients in general. And the potential consequences are much more serious.
Malpractice is likely very much on radiologists' minds when it comes to this issue, and it doesn't help that we're in a society that encourages us to deny liability. In a study conducted by Gallagher et al in 2009, only 15% of radiologists surveyed indicated that they would give a full and transparent disclosure of an error [Radiology, November 2009, Vol. 253:2, pp. 443-52].
Beyond malpractice fears, there's shame and anxiety about the loss of professional standing or potential financial repercussions. And in general, radiologists may not have support from their institutions for disclosing medical errors.
So the culture has been one of reticence to tell patients about errors. What actually happens in the field?
We really don't know what is happening out there in daily practice. I know we've struggled with the issue in our department. There's very little in place on how best to disclose errors we make to patients, and in particular, how to handle errors we find on outside studies.
Why is the issue getting attention now? Are things changing?
The momentum for peer review processes and quality assurance is building, and there's more incentive for developing robust processes for error analysis. As these processes become more comprehensive, we find more retrospective errors and then are presented with the issue of how to deal with them. Things are also changing with the movement toward patient-centered care, which has been embraced within radiology.
In addition, risk managers have historically advised that errors not be discussed with patients and apologies not be offered. But the culture is changing in many institutions: There is more institutional support for disclosure, as risk management's view of the issue has changed.
I think the shift largely began with a report issued in 2000 by the Institute of Medicine called "To Err is Human: Building a Safer Healthcare System." That report found that tens of thousands of preventable deaths occur in hospitals every year. Of course, not all those adverse events are related to errors, but a certain percentage of them are.
The safety and quality movement in medicine, led by organizations such as the Joint Commission, the National Quality Forum, and the Institute for Healthcare Improvement, has promoted the understanding that the disclosure of errors by physicians to patients is a key component of the management of harmful adverse events. These organizations emphasize that accountability, openness, and transparency around adverse events and outright errors are essential to improving the overall safety and quality of medical enterprise. And risk managers are now following suit by encouraging more open disclosure.
Does being open with patients about harmful errors protect radiologists from malpractice?
There is reason to be encouraged. In terms of the effect of error disclosure on malpractice experience, some data published in the Annals of Internal Medicine in 2010 showed that when an academic center implemented an enterprise-wide mechanism for error disclosure that adopted recommendations made by the National Quality Forum and the Institute for Healthcare Improvement [discussion of the harmful events, an investigation, problem-solving for the future, and when necessary, apologies to patients and offers of compensation] there was a decrease in both the number of new compensation claims made and the number of claims paid [Ann of Intern Med, August 2010, Vol. 153:4, pp. 213-221].
So this is one example of the favorable impact that disclosing harmful errors to patients has on medical malpractice experience. But we don't know yet if this experience can be extrapolated to radiologists in all of their varied practice settings.
What do you suggest going forward for addressing this issue?
It would be helpful for radiology leaders to come together to develop guidelines about this issue -- guidelines about what is error, what is harm, when should disclosure be made, and best practices around it. Also important is educational programming. At Children's Hospital Boston, we have a program that teaches radiology residents and fellows general communication skills, as well as specific skills related to error disclosure, using actors who engage with class participants in replicas of actual conversations. We believe that the training best starts at the beginning of a radiologist's career, but the attending radiologists who have participated have also found it quite valuable for their practice.