Disclosure of Unanticipated Outcomes

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Disclosure of Unanticipated Outcomes

• Core Curriculum for Patient Safety

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Disclosure is driven by ethical, regulatory and
patient-centered forces.
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Providers who follow the proper procedure for
disclosing a medical error to a harmed patient
are less likely to be sued for malpractice than
providers who neglect such disclosure.
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Definitions

• Unanticipated outcome
• A consequence of patient care and/or treatment
  that is not a normal risk for a patient of that
  health status e.g., delayed or prolonged
  treatment, injury, diminished capacity.
• Disclosure
• Telling patients important information regarding
  their medical care or condition which affects, or
  has the potential to affect, their well-being,
  and future health-related decisions.

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Error disclosure is a policy, not a choice

• Ethics
• Regulatory requirements
• The patients right to know

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Ethics

• The interests of clients must override the
  self-serving interests of professionals. By
  failing to disclose, a health provider is
  conspicuously placing his or her self-interests
  above the patients.
• -John Banja, Ph.D., Associate Professor of
  Clinical Ethics, Emory University
• Situations occasionally occur in which a patient
  suffers significant medical complications that
  may have resulted from the physicians mistake or
  judgment. In these situations, the physician is
  ethically required to inform the patient of all
  the facts necessary to ensure understanding of
  what has occurred.
• -American Medical Association Code of Ethics

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Regulatory

• JCAHO redisclosure
• The responsible licensed independent practitioner
  (or his or her designee) clearly explains the
  outcome of any treatments or procedures to the
  patient and, when appropriate, the family,
  whenever those outcomes differ significantly from
  the anticipated outcomes.
• -Intent of Standard RI. 1.2.2.

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Patients right to know

• What do you have to tell a patient?
• What should you tell a patient?
• If you were a patient injured by a medical error,
  what would you want to know?

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Disclosure policy and procedure

• Who is responsible for the disclosure?
• Who needs to be notified?
• What (if anything) is written?
• Whats the culture?
• Whats causing any discrepancy between policy
  and culture?

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Who is responsible for disclosing an
unanticipated outcome?

• MD with primary responsibility for the patient
• Alternatives
• When an MD is not directly involved

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Who needs to be notified

• Patient care team
• Risk management office
• Patient and/or family

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What (if anything) is written?

• Institutional policy for disclosing unanticipated
  outcomes to patients
• Procedures for conducting a disclosure discussion

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Whats practiced?

• How is disclosure actually handled here?

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Whats causing any discrepancy?

• How does actual practice differ from written
  policy?
• Why?

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Disclosure is a difficult process

• Sadness/fear/embarrassment
• Legal/malpractice ramifications
• No training/unfamiliar process
• Individual culture/experience

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Sadness/Fear/Embarrassment

• Patient injury
• Patient/family anger
• Colleague disapproval
• Administrative reprisal
• Legal action
• Publicity

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Legal/malpractice ramification

• A patients right
• A relatively rare occurrence
• Insurance coverage/protection
• The value of disclosure

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Unfamiliar process

• Never saw one, never did one, never taught one.

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Individual Cultural/Experience

• It may be your nature to be more or less
  forthright than the situation calls for.
• Any previous experience in this type of
  situation (positive or negative) may influence
  future situations.

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What events need to be disclosed?

• When a patient is harmed by an error
• When a patient is not harmed despite an error
• When disclosure may do more harm than good

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How disclosure is conducted

• Who
• What
• When
• How
• Documentation
• Follow-up

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How disclosure is conducted

• Who meets with the patient (or family)?

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How disclosure is conducted

• Who
• What information is shared?

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How disclosure is conducted

• Who
• What
• When and where is the disclosure held?

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How disclosure is conducted

• Who
• What
• When and where
• How is the discussion facilitated?

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How disclosure is conducted

• Who
• What
• When and where
• How
• Empathize and apologize

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How disclosure is conducted

• Who
• What
• When and where
• How
• Empathy and Apology
• What should (and should not) be documented?

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How disclosure is conducted

• Who
• What
• When and where
• How
• Empathy and Apology
• Documentation
• What type of follow-up is appropriate?

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The second victim

• In November, 2001, a British GP threw himself off
  a cliff after he was accused of causing the death
  of a patient.

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Developing and practicing disclosure proficiency

• Develop and document a process for patient
  focused disclosure
• Practice
• Increase your range of techniques

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Develop and document a process for
patient-focused disclosure
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Practice
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Increase your range of techniques
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Done right, disclosure can reduce an errors
impact on the patient and the provider.

• It is not a choice, it is a policy.
• It is an infrequent and hard-to-do process.
• Preparation and practice will help.