2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Table 1. Key Steps in Disclosing Medical Errors to Patients
and Relatives
● Initiate the conversation in a proper setting.
● Start by saying that the conversation will be difficult and then give an explicit
statement about what happened.
● Talk and respond with humility and sorrow, not with defensiveness.
● Offer a sincere clear apology, including admission of the error and remorse.
● If you are still in training, ask for the presence of a senior staff member.
● Refrain from pointing to someone else or to the system.
● Disclose relevant data and take responsibility.
● Promise that a thorough investigation of the error will be conducted.
● Make sure that precise and timely answers are provided.
● Guarantee constant monitoring of the patient as your priority.
● While keeping an open attitude about possible good outcomes, avoid making
promises you can’t keep, yet state that you hope for the best outcome.
● Set up a follow-up meeting with family members, including anyone else they wish
to involve.
● Offer the help of a patient advocate and legal consultant to assist patient and
relatives.
Disclosure of Medical Errors: Individual and
Cultural Aspects
According to the Institute of Medicine (IOM), the standard
definition of medical errors is “the failure of a planned action
to be completed as intended or the use of a wrong plan to
achieve an aim.” 1 Most patients, however, have a broader
perspective on medical errors than physicians or researchers.
5 For example, they tend to include among medical
errors their physician’s failure to communicate effectively
with them before and after an error has occurred. Individual
physician or institutional arrogance has been described by
some patients with cancer as contributing to their perception
of medical errors and to the possibility of repairing a
breach in trust. 28,29 Furthermore, the absence of physician
empathy and honesty in the aftermath of harmful medical
error not only exacerbates patients’ and family members’
suffering but may be seen as part of the error itself.
Disclosure of medical errors is now an ethical requirement
of the medical profession in the Western world. It cannot be
ignored, however, that disclosing an error is inevitably
related to the different attitudes and practices of providing
information to patients with cancer in different countries
and cultural groups. Clearly, it is considered more difficult,
and it is less common to disclose medical errors in contexts
where the truth about their overall condition and prognosis
is withheld from patients with cancer.
A recent study of surgeon-patient disclosure practices in
Southwestern Nigeria asked 102 surgeons the question: “To
whom should surgical errors be disclosed?” Only 15.7%
replied that the information should be conveyed to the
patient, whereas 30% indicated that it should be delivered to
a family member. Others suggested that errors should be
referred to the hospital ethics committee (22.5%), to hospital
management staff (21.5%), to a colleague (21.5%), or to other
staff members during a clinical meeting (2%). 30
Overall, the authors of the study reported that surgeons
were unsure about whether they should disclose medical
errors. 30 Notably though, participating surgeons valued the
potential benefits of disclosure in a similar way to that of
Western physicians, listing among those benefits: learning
e26
from errors; prevention of further complications; promotion
of honesty, openness, trust and confidence; reduction of risk
of litigation; relieving the doctor’s conscience; and overall
practice improvement. Among the potential risks of disclosing
medical errors they noted litigation and prosecution,
negative effect on practice, loss of trust and confidence, loss
of medical license, undue patient anxiety, and even risk of
physical assault. 30
Conclusion
ANTONELLA SURBONE
Oncologists’ failure to disclose medical errors to their
patients betrays the fiduciary nature of the patient-doctor
relationship and diminishes the integrity of our profession
by silencing patients and family members through neglect of
their stories and experiences, as well as by obfuscating the
effect that errors have on ourselves. 5 Silence may increase
the risk of malpractice suits and is always morally wrong,
for it inevitably adds to the pain of patients and their loved
ones. 21
Further research on the incidence and types of error, near
errors, and perceived errors in oncology, using both qualitative
and quantitative methods, and development of clear
policies and practices regarding disclosure and other posterror
interactions with patients and family members, are
needed. Understanding that, like truth-telling about cancer
diagnosis and prognosis, attitudes toward and practices of
disclosure of medical errors are subject to individual and
cultural variability and should not prevent us from learning
about sensitive communication about medical errors and
from meeting adequate standards of ethical clinical practice
worldwide. Analysis of institutional standards, policies, procedures,
and training regarding disclosure of medical errors
with a focus on how oncologists and other team members
understand and apply these specific communication elements
will guide researchers and practitioners in efforts to
build on current practice.
Mortality and Morbidity Conferences are often a proper
setting for physicians to disclose and discuss their errors,
but they do not provide the setting for expressing emotions
and finding support. Didactic and experiential education
and training regarding responsibility and accountability for
optimal ongoing communication throughout the course of
the patient’s illness, including disclosure of medical errors,
should be enhanced at all levels, from medical school
through internship, to residency and oncology fellowship.
Emphasis should be placed on the redemptive value of
apology and forgiveness for patients and their families and
for oncologists, and on provision of emotional support for all
parties affected by medical errors.
Many compelling physicians’ narratives reporting the experience
of medical errors are available to teach us that
communication of medical errors is not only about disclosure
to patients and families. Rather, it is also about creating a
culture of medicine in which the patient’s interest and
well-being always has priority over physician or institutional
self-interest. This principle and goal can be achieved
through establishing a serene atmosphere of collaboration,
rather than competition, and open communication among all
members of the staff, one in which a medical error is not a
reason to fear punishment or loss of esteem from peers, but
an incentive for all to share, understand, and improve.