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“I’m sorry. I messed up.”
Those words are hard enough to say when you’ve missed a meeting or forgotten a friend’s birthday. When the stakes are as high as a patient’s life or death, or mean the difference between spending an evening at home with family and friends or a night in the hospital listening to alarms and getting blood draws, they can be downright paralyzing. Yet doctors must speak some variation of those words in hospitals across the country every day.
A few years ago, I admitted a young woman who came to the emergency department vomiting and feverish. For several days, she’d had pain when she urinated and aching on her side when she moved — textbook symptoms of a urinary tract infection that had migrated to the kidneys. So we started her on intravenous fluids and tobramycin, a potent antibiotic with potent side effects. Later we learned she had already received a dose in the E.R. — worrisome because tobramycin’s risk of harming the kidneys increases with accumulated doses.
Fortunately, there was no kidney damage, and the patient soon left the hospital fully recovered. She later said she wished she hadn’t known about the double dose. It hadn’t caused her any harm, and added to the anxiety of an already frightening hospital stay.
I think, and research suggests, that most patients would like to know — and know early — if an error has occurred. But my patient’s response highlights the complexity of the issue.
The Institute of Medicine’s 1999 landmark report “To Err Is Human” found that as many as 98,000 deaths occur each year because of medical errors, making them the fifth most common cause of death in the United States. Despite substantial quality improvement efforts since, medical errors remain widespread.
In 2010, the Department of Health and Human Services found that one in seven Medicare beneficiaries experiences an “adverse event” during a hospital stay, half of which are clearly or likely preventable. While an adverse event, which might include a side effect from a drug, is not always a medical error, harm can still ensue. But most such events result in minor or temporary harm; errors that end up in the news, like operating on the wrong patient or body part, are exceedingly rare.
What has become increasingly clear is that talking about medical errors with patients is important. One study at the University of Michigan found that after instituting a policy to improve transparency and open disclosure of medical errors, there were fewer lawsuits, lower liability costs and quicker resolution of claims. Other work generally supports the idea that prompt disclosure and genuine apology reduce the likelihood of legal action. It seems that ethically, legally and financially, it pays to be candid about medical mistakes.
There’s little debate about whether to disclose serious medical errors. But what about minor errors with minimal harm, or technical errors with no clinical consequences? And should errors be disclosed as soon as they occur, or after the causes and consequences are fully understood?
A colleague recently relayed the story of an elderly man he admitted with pneumonia. The man was started on an antibiotic that increased the effect of the blood-thinning medication he had been taking. When the patient woke up slurring his words and unable to move half his body, his family became alarmed. Was his stroke the result of a medical error, a drug interaction that led to excessive blood thinning and bleeding into the brain? It appeared so. But a CT scan revealed that the patient’s stroke was not the result of a bleed, but a clot — the risk of which was the reason he was on blood thinners to begin with. Yes, the patient’s blood was too thin, and yes, he had a stroke. But the former did not cause the latter.
Research suggests that patients and doctors hold very different views about what exactly should be disclosed and how it should be done. Patients want disclosure of all harmful errors, as well as why the error happened, how its consequences will be mitigated, and how similar errors will be prevented in the future. They define medical error broadly — as deviations from standards of care, adverse events and poor service. After an error, they want emotional support from physicians and an explicit apology.
Doctors define errors more narrowly: as significant deviations from accepted standards of care. They refrain from talking about “near misses” and choose their words carefully. They often avoid discussing why the error happened or how recurrences will be prevented, and some worry that an apology might increase the chances of lawsuits, even though research suggests the opposite. They, too, are greatly upset by medical errors, but are unsure about where to find emotional support.
The difficulty of disclosing medical errors is especially acute for medical trainees, who are less sure of their skills and more worried about evaluations and damaging their reputations than seasoned physicians. More than three-quarters of fourth-year medical students and almost all residents report being personally involved in a medical error. But only one-third of them report receiving formal instruction in error disclosure, though over 90 percent express interest in such training.
As a result, many trainees do not feel confident disclosing medical errors, and their attitudes about doing so vary widely. In a recent study that asked medical students and residents whether they would disclose serious errors, 43 percent said they “definitely” would, 47 percent said they “probably” would, and the remainder indicated they would do so only if asked by the patient. It is notable that trainees who had been taught how to disclose medical errors were more willing to do so.
The study also found that as trainees advance, they become more likely to disclose an error but less likely to apologize explicitly for an error or discuss how recurrences could be prevented — two components that patients feel are important for complete error disclosure. A sincere apology and an error prevention plan may offer doctors an opportunity to convert an unfortunate event into a productive conversation, potentially even strengthening the trust between doctor and patient. This approach may also reduce the incidence of lawsuits, as many patients cite insensitivity and a desire to prevent similar errors as motivating factors for legal action.
Unfortunate as it is, medical errors are an inevitable part of medicine. Even the most intelligent, capable and diligent doctors make mistakes. But it is important that they are trained to talk about those mistakes, just as they are trained to deliver bad news, obtain informed consent, or take a respectful sexual history. We must do all we can to honor the ancient creed, “First, do no harm” — but we should also learn to talk about it when we do.
Dhruv Khullar is an incoming medical resident at the Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.