Disclosure of Unanticipated Errors

When unanticipated errors occur when CRNAs deliver anesthesia care to their patients a cascade of events and emotions occur. We are all human, and errors occur. Trying to hide them promotes an appearance that we do not care about our patients. Additionally, when harm comes to our patient the current medical legal system seems to create a two sided rift between our patient and the hospital. Important information about what went wrong is often buried in legality. This leads us to the question: How can we promote our national safety goals as long as the legal system incentivizes hiding, tolerates dishonesty and fosters a barrier between patients and their providers, each seeing the other as “the enemy”?

Communication is a fundamental component of a caregiver to patient relationship. Patient safety is every patient’s right and every clinician’s responsibility. Patients understand that medical errors are inevitable, but they want to know that health care providers and the institution they work for regret what has happened, and they also want to know that lessons have been learned.

Providing information about what happened should reduce patient uncertainty and increase their ability to act in his or her own interest. It also enhances the patient-provider relationship. Disclosure is a process; a beginning not an end, not a single event.

But what about perceptions? 98% of patients desire information of even minor errors. 92% of patients believe they should always be told about complications. 81% of patients believe they should be advised of potential adverse outcomes of complications. On the other side of the coin 60% of physicians believe that patients should always be told about complications and 33% of them believe patients should be advised of potential adverse outcomes of complications. So then why the rift?

Actually, regulatory requirements demand disclosure. Per the JCAHO Standard R1 2.90, patients and when appropriate, their families are informed about the outcomes of care, treatment, and services, including unanticipated outcomes. At a minimum the patient, and when appropriate, his or her family, is informed about the following:

Outcomes of cares, treatment, and services that have been provided that the patient (or family) must be knowledgeable about to participate in current and future decisions affecting the patient’s care, treatment, and services. --Unanticipated outcomes of care, treatment and services that relate to sentinel events considered reviewable by Joint Commission. --The responsible licensed independent practitioner or his or her designee informs the patient (and when appropriate, his or her family) about those unanticipated outcomes of care, treatment, and services.

Unanticipated outcomes or adverse events can be defined as negative or unexpected result from diagnostic tests, treatment or surgical intervention that may or may not be due to medical error; caused by medical management not by disease. An error is an act of omission or commission that would have been judged deficient by peers; failure of planned action to be completed and intended or use of wrong plan to achieve a goal. A preventable adverse event is an injury of complication from error of systems failure. And finally, an unpreventable adverse event is an injury not due to systems failure; rare but known risks of ordinary treatment.

Guidelines regarding disclosure include addressing the patient’s health care needs immediately. Communicate in a compassionate, honest, and timely manner. Follow through on commitments made to patients. Avoid casting blame. Encourage an environment where lessons learned and improved reporting yield better care. Lastly, create or sustain trust by providing truthful, understandable explanations of the even, and how future occurrences will be prevented or minimized.

In reality, disclosing mistakes may reduce the risk of litigation. Serious mistakes may come to light even if they are not disclosed. Any perception of a cover-up may make patients angrier and possibly litigious. Disclosure mitigates emotional distress associated with unanticipated outcomes for patients and health care providers and has NOT been shown to increase liability claims.

Timing of disclosure should occur as soon as practical after the patient’s immediate health care needs have been addressed. It should be timed when the patient is physically and emotionally stable. Ask the patient’s permission to discuss care with their family. Always preserve their privacy, and never jeopardize their health care needs.

When you meet with the patient or family for a disclosure interaction, the licensed independent practitioner, the provider involved in the unanticipated outcome, or responsible for ongoing care as well as the one who will be accepting responsibility and answer clinical questions, should all be present. Additionally, many health care organizations have a health care mediator on staff to assist. The patient is primarily interested in three things: 1. Honest communication: what happened, how consequences will be mitigated (i.e. follow-up care, impact of event); 2. Expression of sympathy/empathy/acknowledgment; and 3. Understanding of what is being done to prevent recurrence in the future. Do NOT share inaccurate information, conjectures, beliefs, opinions or subjective information. Don’t assign blame to other providers or respond demands for immediate answers. Don’t disclose peer review results, names or any disciplinary action. Never offer advice or information regarding compensation. Additionally do not lie, or guarantee what cannot be delivered. Remember that there is not requirement to admit liability. Statements of fault are admissible in court. Patients can forgive a lack of information, but not a lie. Let them know when the information will be available to them.

Some cautions about apologies. Protected apologies are benevolent expression of sympathy “I am sorry that you have been through so much pain”. Admissible (in court) apologies suggest responsibility: “I am sorry I did not have the student nurse anesthetist bring the lab results to me immediately, so I could have treated the underlying problem”. Helpful phrase include ones stating that you are sorry, that you apologize, that you feel terrible. Avoid phrases that state “it’s my fault; it’s her/his fault; we caused this; this shouldn’t have happened; I wish that I had…”

In sum apologizing is very difficult. Shame and fear maintain providers as the second victim. Providers fear peer review, loss of reputation, career impact and legal implications. The bottom line is, as providers we are often devastated. Bear in mind however, the benefits to the patient and their family may outweigh these barriers. They want the truth, and want the organization to take responsibility. Communicating may actually mitigate their anger and sense of betrayal especially if they felt like there is a cover-up or find information later that was not disclosed. It also may ease their sadness, anxiety and depression. Finally, we as providers may need some form of emotional support. Don’t be afraid to get the help you may need to assist you through this challenging experience.