By Christopher Cheney
For patients, the physical, psychological, and financial impact of medical errors can last long after an adverse event.
In 1999, the Institute of Medicine published “To Err Is Human: Building a Safer Health System,” which found that as many as 98,000 Americans were dying annually because of medical errors. Estimates of annual patient deaths due to medical errors have since risen steadily to 440,000 lives, which would make medical errors the country’s third-leading cause of death.
To gauge the long-term impact of medical errors and how healthcare providers can mitigate the harm, HealthLeaders recently spoke with Sigall Bell, MD, director of patient safety and quality initiatives at the Institute for Professionalism and Ethical Practice in Boston. Bell is also director of patient safety and discovery, OpenNotes, at Beth Israel Deaconess Medical Center in Boston. Following is a lightly edited transcript of that conversation.
HL: What are the primary considerations of long-term emotional harm?
Bell: Mounting data suggest that the impact of medical errors on patients and families can be multi-dimensional and prolonged. Patients and families describe physical, financial, emotional, psychological, and sociobehavioral impacts. In a study led by Madelene Ottosen, such impacts were found to last 10 years or longer in some cases.
Emotional harm is gaining accelerated attention in healthcare. It is a critical consideration because unlike the physical injury from medical error and adverse events, it can be much harder to see, and it may further unfold long after patients and families leave the healthcare setting. Patients and families may suffer profoundly from feelings of betrayal, sadness or depression, fear, anxiety or post-traumatic stress disorder, self-blame about the error, and other emotions related to the event.
HL: What are the essential elements of effective communication with a patient and family after a medical error?
Bell: To date, principles of effective communication after medical errors include acknowledging the error, discussing implications for the patient’s health, a sincere apology, plans to prevent recurrences, and discussion of compensation when appropriate. Because some of this information may not be known at the time of the first conversation, it is important to remember that communication after harmful events is a process, not an isolated event.
Disclosure guidelines often emphasize what to say, or at least what topics to cover. It is equally important to think about how to communicate, focusing on genuine empathy, compassion, body language, and making space for emotion. Communication is a two-way street. Although healthcare professionals understandably focus on what they should say, it is crucial to also emphasize listening—making sure that patients feel heard.
HL: What are the most promising ways to support a patient and family after a medical error?
Bell: The growth of Communication and Resolution Programs (CRPs) nationwide offers a promising way to support patients and families after medical errors. CRPs are principled, comprehensive, and systematic approaches to responding to harmful events that help to support all involved stakeholders including patients, families, and clinicians.
In addition to open, honest, and timely communication, CRPs also address financial compensation in appropriate cases, peer support, and improving patient safety as a core mission. This is critical because robust organizational learning and safety improvements are likely limited in a “deny and defend” culture that does not adopt transparent communication.
Optimizing organizational responses to adverse events and medical errors can be challenging. CRPs provide a thoughtful structure, disciplined expectations related to transparency, and coordination of various stakeholders including clinicians, insurers, and risk managers. This helps keep everyone on track and coordinated on the primary goal of supporting patients and families. Further research about the experiences of patients and families over time is needed to guide long-term support after medical error.
HL: What are the most promising ways to address long-term emotional harm?
Bell: We are just beginning to understand the nature and impact of long-term emotional harm and far more work is needed to develop and test best practices to better support patients and families, and ideally prevent such events. As a first step, avoiding factors that can exacerbate emotional harm, such as organizational secrecy, silence, or hidden information is key.
We need to start from the beginning, rethinking taxonomy to define terms such as “harm” and “resolution” in ways that make sense and matter to patients and families. We should also expand the definition of harm to include the many dimensions patients and families experience, such as physical, financial, emotional, psychological, and socio-behavioral effects. Then we can modify existing safety tools to measure, track, and work toward more comprehensive harm prevention. We should focus clinician training on communication and relational skills that respectfully address emotion.
Finally, we need to also extend the timeline with which we consider harm and healing well beyond the event, longitudinally over years. This will have important implications for communication practices and accountability over longer arcs. Most importantly, it will help us better understand how to more fully help patients and families who are harmed by medical care.