Disclosure of patient safety incidents to patients or caregivers is a legal, ethical and professional obligation for physicians. Appropriate disclosure conversations facilitate dialogue during the incident management process and reinforces patient-physician trust. In this month’s episode, Steven and Yolanda discuss the best ways to handle disclosure of patient safety incidents and the importance of efficient communication in addressing patients’ needs throughout the process.
Announcer: You’re listening to CMPA Practically Speaking.
Dr. Steven Bellemare: Hi everyone, Steven Bellemare here.
Dr. Yolanda Madarnas : Yolanda Madarnas. Hi.
Steven: Welcome to our podcast. Yolanda, have you ever heard a colleague say something like, “What were they thinking?”
Yolanda: Yeah.
Steven: When they’re talking about the care of a colleague.
Yolanda: Or, “I can’t believe they did that.”
Steven: “They should not have done that.”
Yolanda: Well that was clearly missed.
Steven: Yeah, I’ve heard those things before...
Yolanda: Yeah, so have I.
Steven: And unfortunately, this typically ends up in someone having to pick up the pieces of a poorly done, incomplete or frankly, inexistent disclosure.
Yolanda: Or someone having to contend with an upset, confused patient, completely unprepared and blindsided.
Steven: In fact, you know what? Many of the complaints or legal actions can start with misunderstandings based on comments from people who only know part of the story.
Yolanda: That’s true. Unexpectedly discovering, or learning about a situation, or there was an unexpected outcome, one that happened under someone else’s care can leave us struggling to find the right words.
Steven: It could be that a patient safety incident wasn’t disclosed to the patient.
Yolanda: Or a patient safety incident that the patient is already aware of, but that you’re only now discovering.
Steven: Or maybe even a situation that you think might be a patient safety incident but you really don’t know.
Yolanda: Much of what is already available as material on this topic, presupposes you were involved in the patient safety incident, and provides guidelines about disclosing it. In this podcast, we thought we’d explore those situations where you perhaps discover a serious medication error, a previously described imaging finding that was not followed up on.
Steven: And we thought we’d discuss what we can do to appropriately support a patient when a patient safety incident occurred but under someone else’s care.
Yolanda: So this isn’t intended to revisit who and how to disclose. We can’t possibly cover all those permutations, and there’s a fair bit of CMPA literature already on this that I’d refer our listeners to.
So first the basics.
Steven: Doctors have an ethical and a legal duty to disclose harm.
Yolanda: CMPA encourages our members to disclose all patient safety incidents to patients and their families, but that may extend to you as a new MRP discovering new information.
Steven: So again, as you said, we have lots of material existing on disclosure of patient safety incidents and generally, our advice is that the most responsible physician at the time of the event should ideally, be the one disclosing the issue.
Yolanda: But you may be left holding the bag and having to do it for whatever reason.
Steven: And it may not be a patient safety incident at all. It may be a perception of a patient safety incident.
Yolanda: And that is a crucial point that is so important for the patient who suffered or thinks they’ve suffered harm. What we say, matters a whole lot.
Steven: Oh absolutely. Harm is a very complex issue. It can occur in a number of different contexts. It could be the evolution of disease, or of a condition that the patient has. It could be a patient safety incident and, in fact, if it is a patient safety incident, Yolanda, there are subtypes of harm as well, right? It could be due to a recognized complication or risk of a procedure or a treatment.
Yolanda: A system failure.
Steven: Or sometimes, provider performance. It could be the physician, the nurse, or any other health care provider that’s been involved in the patient safety incident.
Yolanda: Often, I suspect, it’s a combination.
Steven: In fact, it is. Yeah and when we know something happened, or when we think something may have happened, it’s natural human reaction to want to understand what happened.
Yolanda: Sometimes, wrongly or rightly, we find someone to blame. Deciphering the root causes of a patient safety incident is a very complex task that requires a lot of investigation and study and it’s all the more complicated when an event is thought to have taken place under the care of another health care provider.
Steven: Yeah. You know, if we make a comment, however well-intended, when we don’t understand, or know all the facts, we risk making unprofessional comments and you know this is an important issue. We’ve studied that in certain patient populations, or physician populations I should say at the CMPA, and we know that when there’s a provider issue, and I mean that as opposed to a team issue, or a systems issue, when there’s an issue with the care of a provider. Unprofessional or inappropriate physician manner or behaviour is often alleged in our medico-legal cases. In fact, up to a quarter of our cases, allege an improper manner on the part of the physician.
Yolanda: That’s a big number.
Steven: Yeah.
Yolanda: So, this brings up to our take-home messages for today’s podcast. Disclosure is an ethical, legal and professional obligation on physicians.
Steven: The second one would be that if we discover something that happened under someone else’s care, we should be mindful of how we say that.
Yolanda: And to that point, the third point, is choose your words carefully. To support a patient is important, poorly chosen words can actually perpetuate or cause harm in and of themselves.
Steven: So let’s start with the professional obligation to disclose. When we’re faced with the discovery of what could be a patient safety incident that happened under the care of someone else, we face a dilemma, right? Do we disclose, or do we not disclose? On the one hand, we may be aware of and want to meet our professional duty to disclose.
Yolanda: But we may not want to wander into a premature discussion that might wind up drifting into blame and finger pointing.
Steven: Yeah and we may want to be an advocate for the patient and tell them that something went wrong that shouldn’t have.
Yolanda: And then on the other hand, we might feel that it’s up to the other health care provider to take ownership of the issue and take on the disclosure.
Steven: For sure. Now we may want to be cautious and truthful.
Yolanda: But not appear evasive or covering things up.
Steven: And we may think we know what happened and want to explain it.
Yolanda: But at the same time, we don’t want to throw a colleague under the proverbial bus.
Steven: We have to remember, Yolanda, that it’s not our place to assign accountability for an event. That’s for the courts, the hospital, the regulatory authority, whatever body will be looking at a complaint. That’s for them to do.
Yolanda: And we have to remember that most of the time when we weren’t involved, we’re not going to be able to distinguish between an actual patient safety incident versus a perceived patient safety incident. It’s a very different conversation for each of those scenarios, but the underlying issue is the same. We don’t have all the facts.
Steven: So yes, we do have to attend to disclosure, and we do have to make sure someone tells the patient but there are ways to do that.
Yolanda: And this takes us to take-home message number two: Choose your words carefully. This makes me think of an example that highlights this quite well.
Steven: Okay.
Yolanda: So this is the case of a 32-year-old woman, who was seen by her gynecologist for signs and symptoms of premature ovarian failure. She’s very distraught and tells the gynecologist that the year before or after the delivery of her first child, she developed late onset preeclampsia, wound up in the ICU, and had to have a D&C for retained placental fragments. She wasn’t placed on antibiotics but did develop sepsis and septic pelvic thrombophlebitis afterwards.
Steven: So she was quite sick.
Yolanda: Very sick. So her gynecologist, who wasn’t involved in the care at the time, says well, it’s because of what they did to you at the hospital and she of course, takes on...
Steven: Thought that that was it.
Yolanda: A complaint against the obstetrician who looked after her.
Steven: See Yolanda, that’s a perfect example. Thanks for bringing it. It illustrates the point very well that once a patient hears our comment and particularly if it aligns with what they want to hear or what they perceived may have happened, it becomes their truth even though your comments may be completely off the mark.
Yolanda: As was the case here and we see and know that that can lead to unwarranted medico-legal proceedings: complaints, lawsuits.
Steven: Yeah and see, that’s the take-home message number three right there, isn’t it? Ill-advised comments are a very important form of harm. Harm that can be avoided by carefully choosing our words.
Yolanda: And really, patients aren’t well-served by incomplete information and speculation on our parts.
Steven: No. You know what? While it’s okay to advocate for the patient by asking a question, or suggesting more information is required for you to understand another colleague’s actions, give your colleagues the professional courtesy of addressing the patient and to advocate for their knowing the truth, but by doing ’s concerns, themselves. It’s easy, Yolanda, to want to align with the patient and to advocate for their knowing the truth, but by doing so in an ill-advised manner, you may just land yourself, in fact, a prominent role in potential legal proceedings.
Yolanda: Yeah. Don’t get us wrong, legal proceedings are a right of patients and they have their place.
Steven: Absolutely. And disclosure conversations should be well considered so as to aim to preserve trust in us as health care providers and trust in the profession overall.
Yolanda: So when we find out about events that took place before coming into a patient care scenario, no matter how outrageous, egregious or unbelievable they might be, we really do need to strive to maintain trust. We need to find a way for the patient to trust that we’ve listened to them, we’re hearing them, and that we will help them deal with this harm, real or perceived adverse event without undermining their trust in the other health care providers.
Steven: You know speaking of trust, Yolanda, here’s another example.
Yolanda: [signals agreement]
Steven: This was a baby born at 39 weeks by planned caesarean section. He was born flat and the pediatrician says well of course he’s flat, he looks only 37 weeksbased on his visual inspected at the time when he was resuscitating the baby. So now, you have a baby who needs to go to the NICU unexpectedly and a mother who believes that the obstetrician delivered her too soon. You know and that case ended up eroding the mom’s trust in the obstetrician when, in fact, the pediatrician was incorrect and didn’t appreciate all the dating exercise that had actually been taken on prior to the delivery. That baby was, in fact, 39 weeks.
Yolanda: So this is an excellent example, and I think it might be a good time to share with our listeners the article from The New England Journal of Medicine by Gallagher et al. and the reference will be available on our podcast site. So, it stresses the importance of before initiating a conversation about a possible error to make sure you have the facts, and to give your colleagues the chance to correct mistaken assumptions and join in the disclosure discussions with patients.
Steven: Especially, of course, if they were the ones involved in the care that you have questions about in the first place.
Yolanda: [signals agreement].
Steven: It’s especially important for docs with no direct patient care, Yolanda. I’m thinking here radiologists, pathologists, right? Here’s another example. Family doctor believes a pathologist, or radiologist made a mistake because of an amended report. So, they get an amended report that leads them to believe that the radiologist had misread the imaging, for instance.
Yolanda: That would seem like a perfect setup for the family physician to potentially throw the radiologist or the pathologist under that proverbial bus.
Steven: Yeah. So that situation can potentially be avoided if we pace ourselves, realizing that there’s potentially more to it than can be seen. If we take the time to talk to our colleagues and offer them an opportunity to be present with us when we have the disclosure discussion with the patient, if in fact, there was a patient safety incident at all.
Yolanda: It’s important to remember that non-clinicians, so those who don’t have direct patient care involvement, do have the same duty to disclose as clinicians and being there and sharing in those dialogues with these colleagues, helps us ensure as the story comes out.
Steven: Being there, you know, I understand that people who don’t have direct patient contact may feel a tremendous amount of apprehension at the thought of having a disclosure discussion with patients, but you know, being there helps you ensure that your story comes out.
Yolanda: I’ve had instances on the phone with members, where there was a patient safety incident and the clinician who had the patient in the office with him or her had the non-clinician, in this case, the laboratory specialist, on the telephone during the disclosure discussion. So, he was able to share in more of the fact-finding without physically being present but was still present at that discussion. So, there are multiple models.
Steven: Right and I can imagine how helpful and supportive that must have felt for the patient to say this team cared enough to join in by teleconference to be part of that explanation.
Yolanda: That discussion.
Steven: Yeah. Yolanda, let’s look at a different example here. I’m thinking of a patient who was seen in emergency with a pulmonary embolism. The emergency physician sees a few ECGs from a previous visit that that patient had had at the hospital and sees what he clearly identifies as atrial fibrillation and he discovers that the patient had not been anticoagulated. It’d be easy to rush to the conclusion that well, this AFib was clearly missed and had this patient been anticoagulated, the PE would not have happened, right?
Yolanda: Exactly. It’s so important that we resist the tendency to lay blame because, in fact, we may discover there was a very good reason not to anticoagulate this patient. In this case, this was a patient at high risk for bleeding and for whom anticoagulation was actually relatively contraindicated. So, after a thorough discussion, the clinician and the patient decided not to proceed with anticoagulation.
Steven: Yeah and you see the emergency physician had no way of knowing that with the patient in front of them at that moment. So, you know, we’re all going to end up faced with situations like that, where we do not quite understand the reasoning of the person who provided care ahead of us. So, in a similar situation, the advice we would give is look, raise the issue professionally with the patient, but frame the conversation not as an “I can’t believe they did that,” but rather as “I’ll help you get the information you need.” There’s a piece of information here that I’m missing that you should go and discuss with your previous physician.
Yolanda: So really stressing the principle of explore but don’t ignore. So, it’s okay to acknowledge that you don’t understand the situation but that it may very well be because of lack of critical information.
Steven: In fact, the best thing to do is to encourage the patient to seek more information from the previous provider.
Yolanda: And we can even do it on their behalf, depending on the situation. Like that example I cited of the pathologist present on the phone when we discussed.
Steven: Yeah. I think the most important thing that I can think about here, is to reemphasize that we have to remind ourselves that we were not there. We probably, in fact, most likely, don’t have all the facts to allow us to understand the situation and the version that the patient may present to us, is somewhat going to be filtered through their own understanding and a lack of recollection of detail.
Yolanda: And hopefully, we can trust that the decisions made at that time may have made sense in the context they were in.
Steven: Right. So you know what? While chartings should be thorough, it isn’t always complete as it could be. Surprise, surprise, right? And crucial pieces of information may be missing.
Yolanda: And we’ve come to that point in the podcast again, Steven, for our pearls.
Steven: Wow.
Yolanda: So this sounds like a good time for a documentation pearl.
Steven: Okay. Well, how about this one? Remain objective. Keep your comments and chart notes reflective of facts and observations known to you but without editorializing. Does that make sense?
Yolanda: It does.
Steven: Yeah. How about the communication pearl? You want to go there, Yolanda?
Yolanda: Well, resist the urge to shoot from the hip. Outside of being an expert doing a complete case review, it’s probably not a good idea to comment on another physician’s care. Stick to the facts and commit to gathering more.
Steven: Yeah and, in fact, you know, I think that’s really the best way to support the patient.
Yolanda: And that’s all for today. Well that was our point of view for this episode. I’m Yolanda Madarnas.
Steven: And I’m Steven Bellemare. Remember, when you change the way you look at things...
Yolanda: The things you look at change.
Steven: Oh, I forgot, Yolanda. If people want to send us ideas for podcasts, please do so. You can do that at the address: podcasts@CMPA.org.
Yolanda: Yes, we welcome any suggestions for future podcasts. Thanks again, and talk to you next time.
Steven: Have a good day, guys.
Announcer: These learning materials are for general educational purposes only, and are not intended to provide professional medical or legal advice, nor to constitute a “standard of care” for Canadian health care providers.