JRSM >
Volume 98, Number 7 >
Pp. 307-309
Department of Pathology, College of Medicine, University of Saskatchewan and Royal University Hospital, Saskatoon, Saskatchewan, Canada
Correspondence to: Professor Jay Kalra E-mail: jay.kalra{at}saskatoonhealthregion.ca
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| PREVENTABLE ADVERSE EVENTS |
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What, then, is the argument for being open with the patient and family, even when the repercussions may be unpleasant and costly? We have to remember that inappropriate blame attribution, to serve regulatory needs, will merely alienate professionals and discourage them from participating in system improvements.
The foremost justification is to safeguard public trust in the medical profession, and the responsibility to disclose medical errors is acknowledged in codes of professional ethics.10 But another argument is that patients have a right to information about errors in terms of the respect due to them as persons, and indeed patients expect doctors to recognize this duty.12 In addition, failure to disclose an error during the course of patient care may compromise not only autonomy but also informed consent. For example, disclosure may be essential if a patient is to give consent for treatment of injury caused by an error.13 Thus, failure to disclose information on medical mistakes adversely affects the patient's ability to make an intelligent decision, impairs patient trust in the doctor and increases the likelihood of a malpractice suit.14
| HONEST DISCLOSURE—PROGRESS AND INITIATIVES |
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Australia
In 2002, a committee of the Australian Council for Safety and Quality in
Health Care offered an approach to achieving open and honest communication
with patients after an adverse
event,20 addressing
the interests of consumers, healthcare professionals, managers and
organizations. Like the policy proposed by the US Joint Commission, the draft
standard is flexible in allowing development of local policies and procedures.
The unique aspect of the Australian draft standard is the integration of
disclosure with a risk management analysis and investigation of the critical
event. The level of investigation will depend on grading of the event
according to the extent of injury and the likelihood of its occurrence.
UK
The National Health Service in 2003 declared a 'duty of candour',
whereby doctors and managers must inform a patient of an act of negligence or
omission that causes
harm.21 This scheme
offers the patient a package in the form of remedial care, apologies and
monetary compensation without the need for litigation. The affected patients,
if they accept the compensation package, waive their right to litigate.
Canada
The Royal College of Physicians and Surgeons of Canada in 2002 called for
healthcare systems to promote disclosure on safety issues to all partners
including
patients,22 but no
uniform Canadian guidelines on the subject are yet in place. Reviewing
nationwide practices on adverse event disclosure we found that just a few
licensing bodies had ratified policies for disclosure and discussion of
negative outcomes during patient care. The College of Physicians and Surgeons
of Saskatchewan requires the physician to disclose any adverse events and
errors to the patient or his or her representative as soon as possible during
care, with ten guidelines on the steps in purposeful
disclosure.23 The
College of Physicians and Surgeons of Manitoba requires the physician to avoid
all speculations and state plain facts as known at the
time.24 In 2003,
after lengthy deliberation, the College of Physicians and Surgeons of Ontario
approved a policy that made disclosure of harm to patients a standard of
practice,25 even in
circumstances when such disclosure may result in a complaint or a malpractice
insurance claim. A special aspect of the Ontario College policy is the
guideline for medical trainees (i.e. students or residents), who are advised
to report an adverse event either to their supervisor or to the 'most
responsible physician'. (The policy also specifies that the patient is
free to refuse discussion of the event.) The College of Physicians and
Surgeons of Quebec has no distinct policy on adverse event disclosure to
patients, but synthesizes the concept of disclosure in its code of
ethics.26
In Canada, there is nothing in the nature of the US Joint Commission initiative, making disclosure of adverse events a requirement for hospital accreditation. The absence of laws, federal or provincial, mandating adequate disclosure of an adverse event to the patient is a key area of concern.
| THE DILEMMA OF AN APOLOGY |
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| CONCLUSIONS |
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| REFERENCES |
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Federal/Provincial/Territorial Minister of Health establish new Canadian Patient Safety Institute [www.hc-sc.gc.ca/english/media/releases/2003/2003_99.htm]. Accessed 10 October 2004
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hospitals: preliminary retrospective record review.
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Robertson GB. Fraudulent concealment and the duty to disclose medical mistakes. Alberta Law Rev1987; 25:215 -23
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Kalra J, Saxena A, Mulla A, Neufeld H, Qureshi M, Massey KL. Medical Error: A Clinical Laboratory Approach in Enhancing Quality Care [Abstract]. Clin Biochemistry2004; 37:732 -3
Joint Commission on Accreditation of Healthcare Organization. Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Illinois: JCAHO, 2004
Medical Care Availability and Reduction of Error (Mcare) Act. 13 Pa
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Australian Council for Safety and Quality in Health Care. Draft Open Disclosure Standard. Standards Australia, XX 1234-2002, Draft v5.2
Dyer C. NHS Staff should inform patients of negligent acts.
BMJ2003; 327:7
National Steering Committee on Patient Safety. Building a Safer System—a National Integrated Strategy for Improving Patient Safety in Canadian Health Care. NSCPS,2002
Physician disclosure of adverse events and errors that occur in the course of patient care [www.quadrant.net/cpss/index.html]. Accessed 15 October 2004
Physician disclosure of harm that occurs in the course of patient care [www.umanitoba.ca/colleges/cps/Guidelines_and_Statements/169.html]. Accessed 15 October 2004
Borsellino M. Disclosure of harm to be standard of practice. Medical Post2003; 39(11)
Code of Ethics of Physicians [www.cmq.org/UploadedFiles/cmqcodedeontoan.pdf]. Accessed 15 October 2004
Cohen JR. Apology and organizations: exploring an example from medical practice. Fordham Urban Law2000; 27:1447 -82
Liebman CB, Hyman CS. A mediation skills model to manage disclosure
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Mazor KM, Simon SR, Yood RA, et al. Health plan
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Kalra J. Medical error: an introduction to concepts. Clin Biochem2004; 37:1043 -51[CrossRef][Medline]
Kalra J, Massey KL, Mulla A. Disclosure of errors.
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