Clinical Laboratory News - American Association for Clinical ...

among healthcare workers is whether the
disclosure will do more harm than good to
the patient.
Q: Can you give some examples of when
caregivers feel that disclosure might do
more harm than good?
A: Consider a case where a patient is hopelessly
ill and will die soon. Caregivers sometimes
do not disclose a serious or fatal error
in such cases because they feel it will only
compound the agony of family and friends
of the patient. Or consider a case when an
error is minor and the patient experiences
minimal or no harm. Some providers will
not disclose in this type of case, because
they feel the error disclosure will demoralize
the patient and perhaps make the patient
feel worse.
Q: What are some of the other barriers to
disclosure mentioned by care providers?
A: Caregivers are worried that the disclosure
could precipitate a lawsuit and financial
damages (See Box below). They are
concerned that error disclosure may cause
them to be emotionally harmed due to loss
of reputation and acknowledgement of
personal failure. They report being uncomfortable
reporting errors made by other
care providers, some of whom are close
colleagues or superiors. Last, care providers
find these conversations awkward and feel
they do not have the training or communication
skills to provide error disclosure
correctly.
Q: Is the fear of litigation and accompanying
financial damage justified?
A: This question is not decided and will
not be decided for a long time. Early studies
from a Veteran’s Affairs hospital, the
University of Michigan, and a malpractice
insurer in Colorado suggest that, overall,
there will be less litigation as error disclosure
practices spread. These results are limited,
however, and it is too early to draw a
strong conclusion.
Q: What are the implications of the barriers
to disclosure?
A: There are two major implications. The
first is that the barriers decrease the fre-
quency of disclosure. The second is that
when caregivers choose to disclose, they
choose their words too carefully.
Q: Can you explain what you mean by
“choosing their words too carefully”?
A: One scenario that we have used in research
is to ask physicians what they would
do if their bad handwriting on an insulin
order caused an insulin overdose that seriously
harmed the patient. In this example,
the patient is found unresponsive with critically
low glucose. The patient is transferred
to intensive care and then fully recovers.
More than 65% of the physicians said they
would disclose this error. If they were disclosing
this error, more than 70% of the
physicians would describe what happened
as an error, saying something like: “Your
blood sugar went too low because an error
happened and you received too much insulin.”
The remaining physicians would use
a more generic description, saying, “Your
blood sugar went too low because you got
more insulin than you needed.”
Q: Would they mention the handwriting?
A: This is the interesting part. When given
choices regarding what they would specifically
say about the error, only one-third of
physicians would specifically mention the
cause of the error—in this case, their bad
handwriting. Rather, physicians favored
saying, “This occurred because of a miscommunication
in your insulin order.”
They would only volunteer more information
if the patient asked for clarifying information.
Q: Are you saying there is a gap between
what patients want and what physicians
are giving them regarding the description
of the error?
A: Yes. Patients want to know what specifically
happened and how it will be prevented
in the future. If you do not come out
and say that a specific error occurred, you
cannot meet the patient’s desire to know
why it occurred and how recurrences will
be prevented. In our studies, the approach
favored by most physicians was to provide
a nugget of information but not necessarily
to share the information that patients have
said they would like to hear, unless the patient
asks clarifying questions. The patients
want more than that nugget.
Q: Are patients receiving the apologies
they desire?
A: Physicians are split regarding their approach
to apology. For the bad handwriting
scenario, we gave physicians three choices
regarding how they would apologize. The
first choice was no apology, the second was
an expression of regret stating “I am sorry
barriers that hinder error disclosure
by healthcare Workers
® fear of harming the patient or the patient’s friends or family
® fear of litigation
® fear of financial or emotional damage (loss of reputation)
® awkwardness of the disclosure conversation
® lack of confidence regarding communication skills
that this happened,” and the third was an
apology stating, “I am so sorry you were
harmed by this error.” Patients want the
apology, but physicians split 50-50 between
the expression of regret and the apology.
Q: Besides choosing their words too carefully,
what are the other errors made in
error disclosure?
A: Occasionally, we see too much disclosure,
which is the opposite behavior. The caregivers,
in their desire to be truthful and reduce
some of the emotional burden of the error,
examples of disclosure of a
laboratory error by a laboratory
Technologist to a nurse
The error was a data entry on a troponin, which caused an
incorrect diagnosis of myocardial infarction. The request
for read back has been omitted from the disclosure.
choosing words too carefully: “i am calling to correct a troponin
result. the troponin result on patient John doe from March 14 at 14:52,
which was reported as 57 ng/ml, has been changed to 0.02 ng/ml.”
reasonable disclosure: “i am calling to inform you about a laboratory
error. the troponin result on patient John doe from March 14 at 14:52,
which was reported as 57 ng/ml, has been changed to 0.02 ng/ml.
this was due to a manual, data-entry error. in the laboratory, there was
a specimen for troponin from another patient at the same time as John
doe’s specimen. that patient had a troponin of 57 ng/ml, and we incorrectly
entered that patient’s results into John doe’s record. we are sorry
that we made this error. we are doing a further analysis on this error to
look for ways to prevent its recurrence. we will contact you about this
further analysis in the next 48 hours. please feel free to call the laboratory
supervisor if you have questions.”
disclosing too much: “i am calling to inform you about a laboratory
error. the troponin result on patient John doe from March 14 at 14:52,
which was reported as 57 ng/ml, has been changed to 0.02 ng/ml.
this was due to a manual, data-entry error by a technologist named
Joey. there was a specimen for troponin from another patient in the
laboratory at the same time as John doe’s specimen. that patient had
a troponin of 258 ng/ml, and Joey got all confused as usual and incorrectly
entered the patient’s results into John doe’s record. we are sorry
that Joey made this error. Joey has been having personal problems. He
is in the middle of a messy relationship and taking care of his elderly
parents. He has been making lots of these errors, and everybody has
been talking about it. but management around here is too timid to do
anything, and they are never around anyway, as they are usually taking
some kind of fancy retreat or driving around in their boats. nobody
listens to us, and that is why these things happen. it is a good thing we
didn’t kill the patient. this place stinks. if i had more money, i would
retire. we are doing a further analysis, even though we all know what is
going on. please feel free to call the laboratory supervisor in a few days
if you have additional questions.”
hastily give the patient more information
than the patients desire. Many times, this
information is not accurate, since an accurate
description of an error requires the
time to collect and analyze data.
Q: What are some of the important developments
occurring in the area of error
disclosure?
A: Perhaps the most important development
is the National Quality Forum’s
(NQF) addition of standards for disclosure
to its list of safe practices. I was part of the
committee that developed the standard.
Q: Could you describe NQF’s standards
for safe practices and why they are influential?
A: The NQF endorses a set of safe practices
that are considered fundamental to quality
care. Currently there are 32 such practices.
These practices are based on evidence as
well as expert opinion. The standards were
developed by individual stakeholders working
in collaboration with representatives
from organizations interested in healthcare
quality such as the Joint Commission,
CMS, and the Agency for Healthcare Research
and Quality.
Q: What are some of the key points of the
NQF’s standard?
A: The standard contains the basic charac-
teristics of an effective system for medical
error disclosure. There are two key areas
addressed by the safe practice list. The first
is what information should be given to the
patient. The second set of issues addressed
by the safe practice list is the institutional
support of disclosure so that care providers
can be supported while meeting the needs
of patients.
Q: What are the patient issues?
A: The standard supports the list of patient
desires discussed previously. It supports
giving the patient facts about the error, especially
those facts that support decision
making. In addition, the standard states
that formal apologies, rather than expressions
of regret, should be given when a
clear-cut error or system failure occurs.
Q: What are the institutional requirements
to support disclosure?
A: One of the main institutional requirements
is to give disclosure education to all
healthcare workers who might participate
in an error disclosure. Another requirement
is to make sure that help, in the form
of mentoring or coaching, is available to
healthcare workers. The last recommendation
is to provide emotional support to
everybody involved in the error and the
disclosure. This means healthcare workers,
patients, and the families of patients.
CliniCal laboratory news JuLy 2008 15