Medical Error Communication: Policy and Practice

Main PhD Work
 
Swiss Hospital Survey

Title: Implementation Status of Error Disclosure Standards in Swiss Hospitals

Aim: To establish what stage Swiss hospitals are at in implementing an internal standard concerning communication with patients and families following an error that has resulted in harm

Methods: Hospitals were identified via the Swiss Hospital Association’s website. An anonymous questionnaire was sent during September and October 2011 to 379 hospitals in German, French or Italian. Hospitals were asked to specify their hospital type and the implementation status of an internal hospital standard that provides patients or their relatives are to be promptly informed about medical errors that result in harm

Results: Responses from a total of 205 hospitals were received, a response rate of 54%. Most responding hospitals (61%) had an error disclosure standard or planned to implement one within 12 months. This was 19% higher than the results of a similar survey conducted in Germany in 2010. The majority of responding University (88%) and Acute Care (75%) hospitals had introduced a disclosure standard or were planning to do so. In contrast, the majority of responding Psychiatric (67%) and Rehabilitation (52%) clinics had not introduced a standard or planned to do so

Conclusion: It appears that Swiss hospitals are making good progress in providing institutional support for practitioners disclosing medical errors to patients. This has been shown internationally to be an important factor in encouraging the disclosure of medical errors. However, many hospitals, in particular Psychiatric and Rehabilitation clinics, have no plans to implement error disclosure policies. Research is needed to explore the underlying reasons

Funding: Swiss Academy of Medical Sciences Fonds Grant

Publications:

  • McLennan, S; Engel, S; Ruhe, K; Leu, A; Schwappach, D & Elger, B (2013): Implementation Status of Error Disclosure Standards Reported by Swiss Hospitals. Swiss Medical Weekly, 143, w13820. published online

Survey of Swiss Anaesthesiologists

Aim: To examine Swiss Anaesthesiologists’ attitudes and experiences regarding medical errors, disclosing errors to patient and reporting errors within the hospital

Methods: Mailed surveys to clinically active anaesthesiologists working in Switzerland’s five university hospitals, based on studies previously conducted by Dr Thomas Gallagher in America and Canada. The questionnaire was pre-tested with German and French speaking doctors in order to check the clarity of the questions. Questions in either Likert scale (i.e. “strongly disagree” to “strongly agree”) or Yes/No form inquire about doctors general attitudes towards medical errors and communicating with patients after an error, including factors would lead them to not inform patients of serious errors. Doctors are also asked about their experience with errors, including the impact errors have had on their lives. Finally, doctors are asked about their attitudes and experiences regarding reporting errors within the hospital. Statistical analyses will be performed with SPSS

Funding: Käthe-Zingg-Schwichtenberg-Fonds, Swiss Academy of Medical Sciences

Publications:

  • Manuscript 1: Medical Errors Communication: Cross-sectional survey of Swiss Anaesthesiologists’ Attitudes and Experiences. Target journal: European Journal of Anaesthesiology

  • Manuscript 2: The Emotional Impact of Medical Errors on Swiss Anaesthesiologists. Target journal: Anaesthesia

Interviews with Key Stakeholders

Aim: To examine key stakeholders’ general attitudes towards medical errors, perceived barriers to error communication and potential ways of improving the situation

Methods: Semi-structured, open-ended, face to face interviews with key stakeholders, including quality heads at the 5 university hospitals, quality practitioner with a private federation, law professors, hospital lawyers, chiefs of surgery and anaesthesia, hospital medical director, former Dean of Medicine, private sickness fund representative, liability insurance representative, FMH representatives, Patient Safety Foundation President, Swiss Academy of Medical Sciences President. Interviews recorded and transcribed verbatim. Analysis will be assisted by Atlas.ti

Funding: Käthe-Zingg-Schwichtenberg-Fonds, Swiss Academy of Medical Sciences

Publications:

  • Manuscript 1: Liability Insurance’s Impact on Medical Error Communication in Switzerland: A Qualitative Study. Target journal: Jusletter

  • Manuscript 2: Medical Error Communication in Switzerland. Target journal: Swiss Medical Weekly

Additional PhD Work
 
Interviews with Swiss Nurses

Note: Project conducted by Martin Diebold as a part of a medical master’s thesis. Supervised by Stuart McLennan and Prof. Bernice Elger

Aim: To explore nurses’ attitudes and experiences concerning disclosing errors to patients

Research

Methods: Using purposive and snowball sampling, individual semi-structured interviews were conducted with 18 nurses from two German-speaking cantons in Switzerland between February and May 2012. Interviews were transcribed in German and analyzed using a Grounded Theory approach that elucidated general themes. The most illustrative quotes were translated into English

Results: Nurses attached great importance to errors, and did so for two prevailing reasons: the harm errors cause patients and the opportunity to learn from errors. In general, nurses stated that patients should be informed about every error, but only a very few nurses actually reported disclosing errors in practice. Indeed, many nurses reported that most errors are not disclosed to the patient. Nurses identified a number of barriers to error disclosure that have already been reported in the literature among all clinicians, such as legal consequences and the fear of losing patients’ trust. However, nurses in this study more frequently reported personal characteristics and a lack of guidance from the organisation as barriers to disclosure. Both issues point to a lack of a systematic institutional approach to error disclosure in which the decision to inform the patient should stem from within the organisation and not be shouldered by individual nurses alone

Conclusions: Our study strongly indicates that education regarding error disclosure is needed to strengthen nurses’ competences. Such courses might include simulations and be held in teams usually working together. Nurse managers also could be trained to coach disclosure in their team. Integrating both could answer the call for both leadership and education

Publications:

  • Manuscript 1: Nurses’ Perspectives Regarding the Disclosure of Errors to Patients: A Qualitative Study. Target journal: International Journal of Nursing Studies

Error Disclosure in Germany

Title: Regulating Open Disclosure: A German Perspective

Aim: To make a contribution to the international literature on error disclosure by examining Germany’s current approach to disclosure and to consider possible additional measures that could be implemented to further promote error disclosure in Germany

Methods: Ethical and legal reflection on best policy following review of international and German literature concerning error disclosure, and German national and state professional codes of conduct

Results: While the importance of reporting incidents as part of quality improvement programmes has been recognised, the needs of patients in such situations have not yet been sufficiently addressed. The issue of error disclosure currently plays no significant role in German health policy. However, a number of aspects of the wider regulatory framework appear to be supportive and a recent brochure published by the Coalition for Patient Safety’s is a positive step forward. Without legal certainty and a broad consistent framework that is supportive of error disclosure, it seems unlikely that the attitude and behaviour of practitioners will change towards more transparency and openness

Conclusion: Although the ethical, financial and quality improvement benefits of error disclosure have been shown in the English speaking world, Germany still needs to provide a more supportive and consistent framework that allows practitioner to safely disclose incidents to patients. Findings from Germany are also potentially useful for neighbouring civil law countries such as Switzerland and Austria

Publications:

  • McLennan, S; Beitat, K; Lauterberg, J & Vollmann, J (2012): Regulating Open Disclosure: A German Perspective. International Journal for Quality in Health Care, 24(1), 23-27. published online

Error Disclosure and Apology Laws in Australia

Title: Apology Laws and Open Disclosure

Aim: To examine recent developments in Australia regarding open disclosure and to consider whether Australian apology laws are a necessary or appropriate strategy to promote open disclosure

Methods: Ethical and legal reflection on best policy following review of literature

Results: Australia has been at the forefront of the shift towards openness regarding medical errors with Australian Health Minsters endorsing a national Open Disclosure Standard in 2003. The Australian Commission on Safety and Quality in Health Care decided to review the Standard in 2011 to consider it in light of current research and evidence, and recommend changes to it. With recent research suggesting that saying sorry is a key element of successful disclosure practice, the new Australian Open Disclosure Framework (Consultation Draft June 2012) specifies that the words ‘I am sorry’ or ‘we are sorry’ should be included in an apology or expression of regret. Health professionals and indemnity insurers are often concerned about saying sorry, however, due to the fear that it will be seen as an admission of liability. All Australian states and territories have apology laws that protect apologies given after an ‘incident’ from being used in various legal processes, but generally protect only expressions of regret but not admissions of fault. Commentators have recently argued that the limited legal protection that existing laws provide does little to reduce professionals’ fears and that this situation presents a strong case for law reform that would provide stronger protections directed specifically at the contents of open disclosure conversations. In our view, the assumption that such legal protections can narrow the disclosure gap is misguided. The fear that apologies may be used against health professionals in legal proceedings to prove negligence is not well founded and does not provide a sound basis for implementing such legal protections

Conclusion: Laws that make compassion inadmissible or that protect truthful expressions of responsibility are unnecessary and operate on ethically shaky grounds that risks diminishing the value of apologies and fuelling public cynicism towards the medical profession

Publications:

Apology Laws in Canada

Title: The Legal Protection Of Apologies: An On-going Experiment 

Aim: To examine the use of apology laws in Canada and how they compare to other jurisdictions

Methods: Ethical and legal reflection on best policy following review of literature

Results: “Apology laws” have been widely enacted in the United States (36 states and the District of Columbia), Australia (all 8 states and territories) and Canada (8 out of 10 provinces, and 2 out of 3 territories). Most jurisdictions protect both oral and written apologies, with a minority protecting only oral communications. The protection provided under these laws falls into two general categories: 1) the protection of expressions of sympathy; 2) the protection of expressions of sympathy and admissions of fault. Apology laws in the United States (29 out of the 36 laws) and Australia (6 out of the 8 laws) typically protect only expressions of sympathy. In contrast, all of the apology laws enacted in Canada to date protect both expressions of sympathy and admissions of fault

Publications:

  • Currently under review at the Canadian Medical Association Journal. Revision being drafted after peer review feedback

 Forced Apologies

Title: Should Health Care Providers Be Forced to Apologise After Things Go Wrong?

Aim: To examine the appropriateness of healthcare providers being forced to apologise

Methods: Ethical and legal reflection on best policy following review of literature

Results: The issue of health care providers offering apologies to patients when medical errors occur has been a subject of interest and debate within medicine, politics, and the law since the early 1980s. Although apology serves several important social roles, including recognising the victims of harm, providing an opportunity for redress, and repairing relationships, compelled apologies ring hollow and ultimately undermine these goals. Apologies that stem from external authorities’ edicts rather than an offender’s own self-criticism and moral reflection are inauthentic and contribute to a “moral flabbiness” that stunts the moral development of both individual providers and the medical profession. Following a discussion of a recent case from New Zealand in which a midwife was required to apologise not only to the parents but also to the baby, it is argued that the practice of requiring health care providers to apologise to anyone should be reconsidered

Publications:

  • Manuscript currently under review at the Journal of Bioethical Inquiry

↑Index

Who is who

Research

Stuart Roger McLennan

Institute for
Biomedical Ethics

Universität Basel
Bernoullistrasse 28
CH-4056 Basel

Tel. +41 (0)61 267 09 63