Nurses know the value of reporting errors but feel conflicted about disclosing a mistake, according to a recent study in the Journal of Patient Safety.1 Researchers asked nurses about their medical-surgical decision making and learned that nurses have different perceptions of error reporting. Time pressures and whether or not the patient was harmed factored into some nurses’ decision making. The nurses also indicated that after reporting an error, they rarely heard about the outcome of reported mistakes. Fear of disciplinary actions and loss of their jobs were other concerns that nurses identified.1
Doing the Right Thing
Disclosing an error may not be easy, but ethically it’s the right thing to do. The American Nurses Association’s Code of Ethics for Nurses (4.2) states: “Accountability means to be answerable to oneself and others for one’s actions. In order to be accountable, nurses act under a code of ethical conduct that is grounded in moral principles of fidelity and respect for the dignity, worth, and self-determination of patients. Nurses are accountable for judgments made and actions taken in the course of nursing practice, irrespective of healthcare organizations’ policies or providers’ directives.”2(p8) The decision to own up to an error is an individual’s personal decision, but not divulging an error can put the patient’s safety and well-being, as well as other patients’ safety and well-being, at risk.
The Joint Commission asked health care organizations (HCOs) to develop disclosure programs, which range from simple statements to detailed disclosure procedures. In 2001, The Joint Commission issued the first nationwide disclosure standard that requires patients to be informed about medical errors, and The Institute of Medicine called upon states to create mandatory reporting systems to collect information about hospital-based adverse events.3 Twenty-seven states now require hospitals to report “never events,” a requirement that’s begun to force hospitals to adopt much more powerful and nimble strategies to analyze errors.4,5
Since 2001, an explosion of research and articles has shed light on the progress of these programs. In October 2010, the Agency for Healthcare Research and Quality (AHRQ) released a report, “Medical Error Reporting Demonstration Evaluation Projects.” The report is encouraging because it shows that an increase in the rate of error detection can be directly linked to improvements in medical error reporting.6 On the other hand, it also indicates that in spite of The Joint Commission’s requirement for hospitals to disclose all unexpected outcomes of care, how medical errors are disclosed appears to be highly variable. Some providers worry that by disclosing errors, they’re opening themselves up for medical malpractice claims. The study found the opposite: that prompt and full disclosure reduced malpractice claims and settlements.6
The University of Michigan Health System in Ann Arbor, a leader in adopting full disclosure, analyzed records for 1131 malpractice claims or requests for compensation due to medical error between 1995 and 2007, or several years before and after the full disclosure program was implemented. The average monthly rate of new malpractice lawsuits filed against the hospital fell by more than half. The median time for resolving claims also dropped by several months, while the mean costs for liability, including compensating patients and attorneys, fell by about 60%.5
For nurses to become more involved in a disclosure program, health care administrators and organizations need to change the “culture of blame.” This long-standing culture is known for pointing fingers at the professional involved in the error.
Opening the Lines of Communication
The goal of disclosure is to start communication about medical errors between the HCO and its professionals, and the patient or family. The patient and family’s anger may lessen because they’ve been made aware of the error, and an investigation of the error may provide information that helps prevent similar errors from occurring again.
Patients have become better educated and more involved in their own care. Because patients are now playing a bigger role in managing their health care, they may want to be involved in every aspect of their care and learn about unexpected outcomes. According to AHRQ, the patient’s priorities are for the HCO or provider to:
• disclose all harmful errors
• explain why the error occurred
• tell how the error’s effects will be minimized
• provide steps the health care provider (and organization) will take to prevent recurrences.7
Secrecy and Lawsuits
Without disclosure policies, patients and families may initiate medical malpractice lawsuits just to find out what happened. Defense and plaintiff attorneys agree that many people initiate lawsuits out of frustration and anger. Believing that the facility is withholding information or covering up, they may file a malpractice lawsuit to learn the truth. Patients are very aware of what’s happening to them and know when something isn’t right. Most patients would rather be told the truth when something happens than discover it on their own.
Saying You're Sorry
One example of a successful disclosure program is the Sorry Works! Program. Launched in 2005, the program is dedicated to promoting full disclosure and apologies for medical errors.8 The facility must first adopt a disclosure policy and procedure that defines issues such as which errors to disclose. The Sorry Works! Program is guided by the belief that if an error reaches a patient, disclosure is appropriate. As nurses, we already practice a form of disclosure when we tell a patient about a late medication or a missed treatment. After the program defines its policies and procedures, the program is presented to the entire organization. One of the reasons the Sorry Works! Program is so successful is that everyone in the facility is involved.8
Some health care professionals worry that the apology may seem like an admission of guilt. To address this concern, many states have developed apology laws that allow medical professionals to offer an apology without it being considered an admission of guilt. Thirty-seven states have aNudopted apology laws.9
Changing the culture of blame
The good news is that more HCOs are beginning to understand the benefits of disclosure programs and are tailoring them to fit their policies. Disclosure policies shift the intent from avoiding litigation by all means to systems that include fostering teamwork, turning an error into an opportunity to improve patient safety, and doing the right thing for everyone involved. More errors might be reported when clinicians have clear guidelines about what to report, well-defined reporting mechanisms and the training to use them, a blame-free mentoring environment, and routine follow-up of error reports. Health care administrators and organizations should take this opportunity to reach out to nurses, and nurses should feel comfortable doing the right thing.
References
1. Elder NC, Brungs SM, Nagy M, Kudel I, Render M. Nurses’ perceptions of error communication and reporting in the intensive care unit. J Pat Saf. 2009;4(3):162-168.
2. American Nurses Association. Code of Ethics for Nurses with Interpretative Statement. http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.aspx. Accessed August 30, 2011.
3. Department of Health and Human Services, Office of the Inspector General. Adverse events in hospitals: state reporting systems. http://www.oig.hhs.gov/oei/reports/oei-06-07-00471.pdf . Published 2008. Accessed August 30, 2011.
4. Agency for Healthcare Research and Quality (AHRQ). Never events. http://psnet.ahrq.gov/primer.aspx?primerID=3. Accessed August 30, 2011.
5. University of Michigan Health System. Efforts to encourage disclosure of medical errors decreased claims. ScienceDaily. http://www.sciencedaily.com/releases/2010/08/100816204210.htm . Published August 16, 2010. Accessed August 30, 2011.
6. Agency for Healthcare Research and Quality (AHRQ). Patient Safety Initiative. Medical error reporting demonstration evaluation projects. http://www.ahrq.gov/qual/pscongrpt/psini1b.htm . Published October 2010. Accessed August 31,2011.
7. Agency for Healthcare Research and Quality (AHRQ). Patient Safety Network. Patient Safety Primer. Error disclosure. http://psnet.ahrq.gov/primer.aspx?primerID=2 . Accessed September 1, 2011.
8. Sorry Works! Coalition Web site. http://www.sorryworks.net . Accessed August 29, 2011.
9. Wachter RM. Patient safety at ten: unmistakable progress, troubling gaps. Health Affairs. 2010;29(1):1-9. http://hospitalmedicine.ucsf.edu/downloads/patient_safety_at_ten.pdf. Accessed September 1, 2011.
This risk management information was provided by Nurses Service Organization (NSO), the nation's largest provider of nurses’ professional liability insurance coverage for over 650,000 nursing professionals since 1976. NAON endorses the individual professional liability insurance policy administered through NSO and underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an email to service@nso.com or call 1-800-247-1500. www.nso.com.
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