Communicating Medical Errors

Patients report wanting to be told about all harmful errors in their care, and consider disclosures an important part of a trusting relationship with their physicians (1)

Unanticipated unfavorable outcomes are expected in complex modern medicine. How will you like your doctor to disclose unanticipated unfavorable outcomes? Life teaches many lessons.

Carl Jung (Memories, Dreams,Reflections) wrote that acquiring knowledge removes us from the mythic world of instinctive understanding-but life, in which we accumulate vast knowledge, teaches different lessons; that both worlds are compatible, given a certain genius for reflective self questioning. Here in lies the secret of the good life at the clinical, and the mythic, bedside.

MAMMOGRAM ERRORS

Mammogram is a radiological test done to screen, detect and stage breast Cancer.

In a recent study “Disclosing Harmful Mammography Errors to Patients” Thomas H. Gallagher et al(2) tried to assess the attitudes about disclosing errors to patients by using a survey with a vignette involving an error interpreting a patient’s mammogram leading to a delayed diagnosis. This study was based on a survey which included items on demographics, practice characteristics, and experience in radiology and breast imaging.

To assess radiologists’ attitudes about disclosing errors to patients, the survey contained a vignette involving an error interpreting a patient’s mammogram, leading to a delayed cancer diagnosis:

“A diagnostic mammogram for a new palpable lump shows an obvious malignant lesion. You realize a mistake was made in your prior interpretation of this woman’s last screening mammogram. Prior films had apparently been put up in reverse order, and you mistakenly concluded that the calcifications were decreasing in number when they were actually increasing. Your prior incorrect interpretation has resulted in a delayed diagnosis”(2)

Only 14% of radiologists reported they would ‘definitely disclose” this hypothetical mammography error to a patient, and 15% would tell the patient explicitly that an error had occurred during the interpretation of prior films.

The main barriers identified in not disclosing were

1. Fear of Litigation

2. Lack of confidence in communications skills

3. Concern about patient distress (whether disclosure will
be in best interest of patient)

Most physicians’ reluctance to disclose harmful medical errors may reflect more than simple self protection. Patient distress may outweigh any benefit the information may have. Cancer is treated at the stage in which it is diagnosed, and the effect of any delayed cancer diagnosis is irreversible. Thus physicians may question whether informing this patient about the error would be helpful.

ORGANIZATIONAL CULTURE: THE WAY WE DO THINGS HERE

This study makes one reflect on the organization and milieu of modern health care delivery systems. Organizational culture is a set of values normal and beliefs that are reflected in an organization’s structures and systems, including it’s customs, stories, symbols, traditions and rituals, and the language in which all these facets are expressed. In common parlance we talk of the different atmospheres and differing ways of doing things in different organizations (the way we do things here).

Intuitively, an organizational culture is easily appreciated, but it is hard to define in a formal sense. Hence we have doctors who say that they just want to earn a decent honest living without getting into the legal and financial complexities of modern medicine.

But can they be left alone?

There are detractors who say that they can be isolationist only at the cost of being left behind. Modern hospitals with their costly medicines and equipments have much more than just being people oriented. There are annual maintenance contracts, insurance and legal issues to handle.(to name a few)
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Is fear distorting the science and practice of modern medicine to an unhealthy extent?

Note: A modified version of this article has been published In a Radiology portal. Those interested can go to this link and see how the medical community responds.
http://www.iradix.in/472-Unanticipated-unfavorable-Outcomes-Communica ting-Errors.html