Disclose and Discuss Errors; Don't Defend, Deny

SAN FRANCISCO – Changing the clinical culture so that physicians were more willing to talk with patients about medical and surgical errors increased the number of errors reported, decreased lawsuits and legal costs, and improved safety at one institution.

"It used to be a ‘defend and deny’ culture," said Dr. Darrell A. Campbell Jr., professor of surgery and chief of clinical affairs at the University of Michigan, Ann Arbor. "Now it’s ‘disclose and discuss.’ "

The University of Michigan Health System’s "Disclosure of Unanticipated Outcomes" policy requires physicians to give patients "full disclosure of results, including results that differ significantly from what was anticipated" to allow patients to make informed decisions about future medical care, he said at the annual clinical congress of the American College of Surgeons.

The policy was inspired by a 1994 study showing that there are four main reasons patients sue medical caregivers: they need an explanation; they want to ensure the safety of others; they want a sense of accountability; and they seek compensation (Lancet 1994;343:1609-13).

Under the policy’s driving principles, the health system will defend medically appropriate care vigorously but will compensate quickly and fairly when inappropriate medical care causes injury and will learn from mistakes to improve patient safety and communication. The health system is able to compensate quickly and fairly because it is a closed-staff model covered by a captive insurance company, Dr. Campbell said.

Reports of errors and "risk management events" more than doubled since full implementation of the policy in February 2004, from 6,706 in 2004 to 15,650 in 2007, Dr. Campbell said. "I think people feel much more comfortable reporting errors" now.

A comparison of data from 2001 (before the policy) and 2005 (after the policy) found that the number of claims and lawsuits fell from 262 to 114, the average time to resolve claims and lawsuits decreased from 21 months to 10 months, and annual litigation costs declined from $3 million to $1 million, he said.

"It used to be a ‘defend and deny’ culture. Now it’s ‘disclose and discuss.’ "

A retrospective study by other investigators looked at the university’s experience from 1995 to 2007 and reported similar findings. The average monthly rate of new legal claims decreased from seven per 100,000 patient encounters to less than five per 100,000 patient encounters after adoption of the disclosure policy. The median time to resolve claims decreased from 1.36 to 0.95 years, and costs decreased for total liability, patient compensation, and legal costs not related to compensation (Ann. Intern. Med. 2010;153:213-21).

The money saved under the new policy has been redirected to patient safety programs, he said.

Dr. Campbell, a surgeon specializing in liver transplantation, described a case that went awry to illustrate possible responses to the situation. A 9-month-old girl undergoing a liver transplant had a small-diameter hepatic artery. Although the surgeon communicated to the anesthesiologist that the patient should not be overtransfused, the message may have been lost during a patient handoff when the anesthesia team changed. The first postoperative hematocrit was 50%, the hepatic artery thrombosed, and the patient required retransplantation.

Prior to the full-disclosure policy, it might have been tempting to tell the patient’s parents, "These things happen," he said. While this is true, and it may avoid litigation, it’s not the whole truth. Caregivers would feel bad about it, the clinical safety culture would suffer, nothing would be learned, and the same problem could happen again.

If the physician instead says to the parents, "I’m concerned about what just happened. Let’s talk," the conversation is more difficult and could lead to litigation, but it’s an honest approach that augments doctor-patient trust and the culture of safety, which should make caregivers feel better, he said.

"Let’s talk" does not mean the surgeon should make reckless comments, Dr. Campbell stressed. It would not be helpful to say, "Anesthesia is incompetent," or "The fellow dropped the ball," or "I should have been notified earlier," or "I did a perfect operation," or "Somebody’s head will roll," for example.

Disclosing an unanticipated outcome should sound something like the following, he suggested: "This was an unexpected result. I am going to investigate fully. You have the right to know the whole story – the facts. I will tell you what I learn, but not right now."

That provides a window for exploring other possible complications in the case he described, he said. There may have been a laboratory or transcription error. An artery may have been open at the time of reexploration and not seen on relatively insensitive ultrasound. A technical error could have been made, or the patient may have had a humorally mediated rejection of the organ.

The full-disclosure policy is "pretty dramatically different than what we’ve done before," he said.

Dr. Campbell said he has no relevant conflicts of interest.

SAN FRANCISCO – Changing the clinical culture so that physicians were more willing to talk with patients about medical and surgical errors increased the number of errors reported, decreased lawsuits and legal costs, and improved safety at one institution.

"It used to be a ‘defend and deny’ culture," said Dr. Darrell A. Campbell Jr., professor of surgery and chief of clinical affairs at the University of Michigan, Ann Arbor. "Now it’s ‘disclose and discuss.’ "

The University of Michigan Health System’s "Disclosure of Unanticipated Outcomes" policy requires physicians to give patients "full disclosure of results, including results that differ significantly from what was anticipated" to allow patients to make informed decisions about future medical care, he said at the annual clinical congress of the American College of Surgeons.

The policy was inspired by a 1994 study showing that there are four main reasons patients sue medical caregivers: they need an explanation; they want to ensure the safety of others; they want a sense of accountability; and they seek compensation (Lancet 1994;343:1609-13).

Under the policy’s driving principles, the health system will defend medically appropriate care vigorously but will compensate quickly and fairly when inappropriate medical care causes injury and will learn from mistakes to improve patient safety and communication. The health system is able to compensate quickly and fairly because it is a closed-staff model covered by a captive insurance company, Dr. Campbell said.

Reports of errors and "risk management events" more than doubled since full implementation of the policy in February 2004, from 6,706 in 2004 to 15,650 in 2007, Dr. Campbell said. "I think people feel much more comfortable reporting errors" now.

A comparison of data from 2001 (before the policy) and 2005 (after the policy) found that the number of claims and lawsuits fell from 262 to 114, the average time to resolve claims and lawsuits decreased from 21 months to 10 months, and annual litigation costs declined from $3 million to $1 million, he said.

"It used to be a ‘defend and deny’ culture. Now it’s ‘disclose and discuss.’ "

A retrospective study by other investigators looked at the university’s experience from 1995 to 2007 and reported similar findings. The average monthly rate of new legal claims decreased from seven per 100,000 patient encounters to less than five per 100,000 patient encounters after adoption of the disclosure policy. The median time to resolve claims decreased from 1.36 to 0.95 years, and costs decreased for total liability, patient compensation, and legal costs not related to compensation (Ann. Intern. Med. 2010;153:213-21).

The money saved under the new policy has been redirected to patient safety programs, he said.

Dr. Campbell, a surgeon specializing in liver transplantation, described a case that went awry to illustrate possible responses to the situation. A 9-month-old girl undergoing a liver transplant had a small-diameter hepatic artery. Although the surgeon communicated to the anesthesiologist that the patient should not be overtransfused, the message may have been lost during a patient handoff when the anesthesia team changed. The first postoperative hematocrit was 50%, the hepatic artery thrombosed, and the patient required retransplantation.

Prior to the full-disclosure policy, it might have been tempting to tell the patient’s parents, "These things happen," he said. While this is true, and it may avoid litigation, it’s not the whole truth. Caregivers would feel bad about it, the clinical safety culture would suffer, nothing would be learned, and the same problem could happen again.

If the physician instead says to the parents, "I’m concerned about what just happened. Let’s talk," the conversation is more difficult and could lead to litigation, but it’s an honest approach that augments doctor-patient trust and the culture of safety, which should make caregivers feel better, he said.

"Let’s talk" does not mean the surgeon should make reckless comments, Dr. Campbell stressed. It would not be helpful to say, "Anesthesia is incompetent," or "The fellow dropped the ball," or "I should have been notified earlier," or "I did a perfect operation," or "Somebody’s head will roll," for example.

Disclosing an unanticipated outcome should sound something like the following, he suggested: "This was an unexpected result. I am going to investigate fully. You have the right to know the whole story – the facts. I will tell you what I learn, but not right now."

That provides a window for exploring other possible complications in the case he described, he said. There may have been a laboratory or transcription error. An artery may have been open at the time of reexploration and not seen on relatively insensitive ultrasound. A technical error could have been made, or the patient may have had a humorally mediated rejection of the organ.

The full-disclosure policy is "pretty dramatically different than what we’ve done before," he said.

Dr. Campbell said he has no relevant conflicts of interest.

SAN FRANCISCO – Changing the clinical culture so that physicians were more willing to talk with patients about medical and surgical errors increased the number of errors reported, decreased lawsuits and legal costs, and improved safety at one institution.

"It used to be a ‘defend and deny’ culture," said Dr. Darrell A. Campbell Jr., professor of surgery and chief of clinical affairs at the University of Michigan, Ann Arbor. "Now it’s ‘disclose and discuss.’ "

The University of Michigan Health System’s "Disclosure of Unanticipated Outcomes" policy requires physicians to give patients "full disclosure of results, including results that differ significantly from what was anticipated" to allow patients to make informed decisions about future medical care, he said at the annual clinical congress of the American College of Surgeons.

The policy was inspired by a 1994 study showing that there are four main reasons patients sue medical caregivers: they need an explanation; they want to ensure the safety of others; they want a sense of accountability; and they seek compensation (Lancet 1994;343:1609-13).

Under the policy’s driving principles, the health system will defend medically appropriate care vigorously but will compensate quickly and fairly when inappropriate medical care causes injury and will learn from mistakes to improve patient safety and communication. The health system is able to compensate quickly and fairly because it is a closed-staff model covered by a captive insurance company, Dr. Campbell said.

Reports of errors and "risk management events" more than doubled since full implementation of the policy in February 2004, from 6,706 in 2004 to 15,650 in 2007, Dr. Campbell said. "I think people feel much more comfortable reporting errors" now.

A comparison of data from 2001 (before the policy) and 2005 (after the policy) found that the number of claims and lawsuits fell from 262 to 114, the average time to resolve claims and lawsuits decreased from 21 months to 10 months, and annual litigation costs declined from $3 million to $1 million, he said.

"It used to be a ‘defend and deny’ culture. Now it’s ‘disclose and discuss.’ "

A retrospective study by other investigators looked at the university’s experience from 1995 to 2007 and reported similar findings. The average monthly rate of new legal claims decreased from seven per 100,000 patient encounters to less than five per 100,000 patient encounters after adoption of the disclosure policy. The median time to resolve claims decreased from 1.36 to 0.95 years, and costs decreased for total liability, patient compensation, and legal costs not related to compensation (Ann. Intern. Med. 2010;153:213-21).

The money saved under the new policy has been redirected to patient safety programs, he said.

Dr. Campbell, a surgeon specializing in liver transplantation, described a case that went awry to illustrate possible responses to the situation. A 9-month-old girl undergoing a liver transplant had a small-diameter hepatic artery. Although the surgeon communicated to the anesthesiologist that the patient should not be overtransfused, the message may have been lost during a patient handoff when the anesthesia team changed. The first postoperative hematocrit was 50%, the hepatic artery thrombosed, and the patient required retransplantation.

Prior to the full-disclosure policy, it might have been tempting to tell the patient’s parents, "These things happen," he said. While this is true, and it may avoid litigation, it’s not the whole truth. Caregivers would feel bad about it, the clinical safety culture would suffer, nothing would be learned, and the same problem could happen again.

If the physician instead says to the parents, "I’m concerned about what just happened. Let’s talk," the conversation is more difficult and could lead to litigation, but it’s an honest approach that augments doctor-patient trust and the culture of safety, which should make caregivers feel better, he said.

"Let’s talk" does not mean the surgeon should make reckless comments, Dr. Campbell stressed. It would not be helpful to say, "Anesthesia is incompetent," or "The fellow dropped the ball," or "I should have been notified earlier," or "I did a perfect operation," or "Somebody’s head will roll," for example.

Disclosing an unanticipated outcome should sound something like the following, he suggested: "This was an unexpected result. I am going to investigate fully. You have the right to know the whole story – the facts. I will tell you what I learn, but not right now."

That provides a window for exploring other possible complications in the case he described, he said. There may have been a laboratory or transcription error. An artery may have been open at the time of reexploration and not seen on relatively insensitive ultrasound. A technical error could have been made, or the patient may have had a humorally mediated rejection of the organ.

The full-disclosure policy is "pretty dramatically different than what we’ve done before," he said.

Dr. Campbell said he has no relevant conflicts of interest.