Why Hospitals Should Disclose Medical Error

By Rick Boothman, JD

4.8 million. Each year in the United States alone, an estimated 4.8 million hospital patients suffer serious harm through preventable causes.

This alarming statistic is the driving factor behind Press Ganey’s Safety 2025 Initiative, which challenges the healthcare industry to achieve an 80% reduction in patient harm by 2025. Accomplishing this feat will take a systemic rethinking of the approach to addressing medical malpractice.

My professional life began as a trial lawyer defending hospitals and healthcare professionals accused of medical malpractice. The expectations of me were clear from the start: deny charges of malpractice and find a way to defend the care at issue. Patients would get explanations only after an expensive fight in court and we would find a way to defend the care provided, even if privately my clients were not proud of that care. Over time, I realized that no one was learning anything from these serious safety events.

This realization would lead me to the next chapter in my professional life: leading Michigan Medicine’s health system litigation risk and claims management efforts.

I began with a simple notion: “deny and defend” was not serving anyone. In fact, it was perpetuating patient harm and driving up malpractice claims.

There was a better way, paved by honesty, transparency, and prioritizing patient safety. The approach would soon come to be known as the “Michigan Model”—a communication and resolution program that offers patients harmed by preventable medical errors explanations, apologies, and compensation while accelerating clinical improvement toward a goal of zero harm.

Honesty

Though skeptics were certain honesty would lead to financial catastrophe, it has proven indispensable to clinical improvements. Safety improvements accelerated and claims cost and numbers dropped.

I’ll give an example—a patient had an uncomplicated procedure to address abnormally formed blood vessels. Later, the patient began showing early signs of a possible stroke, potentially caused by a bleed or clot. After the neuroradiologist reported no evidence of a bleed, the resident administered a blood thinner that nurses pulled from a bin. The patient immediately improved, but then suddenly crashed. Follow-up scans showed a massive bleed deemed inoperable.

As the team explained to the family that bleeding was an inescapable risk of the procedure and the blood thinner used, the resident self-reported to me that he had administered a 10-fold overdose. The medication label, known to be problematic in other overdose events, showed 1,000 in large print, but “X 10” in smaller print.

Through tears and heartfelt apology, the resident disclosed the mistake to the patient’s family. In a tense moment of shock and disbelief, the patient’s sister crossed the room and embraced the young surgeon. “Please don’t forget my sister,” she said. “But don’t you dare quit! We’ve watched you, and you really care. You’ll do a lot of good for a lot of people in your career. Don’t you dare quit over this.” With that profound act of forgiveness, she likely rescued that young surgeon.

The cause of the mistake was identified almost immediately. The blood thinner was available loose in a bin. Had the nurses assisting the resident obtained the medication from the pharmacy, the overdose could have been avoided.

Within 24 hours, stricter practices regarding the use of, and access to, medications were put in place to help prevent the same mistake from happening in the future, and the team involved was given time off with counseling and emotional support.

Transparency

Similarly, when unintended harm occurs despite appropriate care, transparency often spares patients and caregivers unnecessary litigation—even when a patient is poised to sue.

In an early experience, an ophthalmologist encountered a nightmare complication when treating a patient who had eye surgery to correct nearsightedness. The surgery ultimately left the patient with impaired vision.

The patient hired an attorney, who agreed to a meeting believing that a settlement would be offered.

The patient and his lawyer were surprised when the ophthalmologist greeted the patient with genuine sorrow and compassion. Then, after revisiting the informed consent, the ophthalmologist explained patiently why the complication was not the result of medical error. After a lengthy—and sometimes stormy—meeting, the patient instructed his lawyer to stop preparing for litigation and asked the ophthalmologist to take him back as a patient.

Reports were made immediately to the federal government and the surgical instrument manufacturer. Training was held, refining the way informed consent was communicated for that procedure, and the patient relationship was restored.

Accountability

In both cases, a “deny and defend” response would have left the patients and families no alternative but to sue, compounding the trauma already felt by the patients, families, and caregivers, but likely leaving healthcare professionals jaded and feeling betrayed by their own health systems. Worst of all, other patients would have been at risk, as there would likely have been no positive change from any lessons learned.

The goal of achieving zero harm is noble and necessary, but impossible without honesty and transparency. By owning and embracing its errors, an organization can develop the appropriate steps to avoid those same errors in the future, ultimately positioning itself for growth, better patient experience, and lower numbers of claims.

Commitment to excellence

By striving to put more of an emphasis on honesty, transparency, and accountability, together we can enact real change and advance our shared commitment to zero harm.

It starts by putting the patient, and safety, first. When the patient and safety are the priority, all else will be aligned to achieve organizational success.

Rick Boothman, JD, is a strategic consultant at Press Ganey.