Like me, many of my colleagues were never taught how to disclose errors in medical school. Errors were considered incidental lapses and used as teaching points among residents; we were not to discuss them with patients unless absolutely necessary. When I joined a private practice 18 years ago, our hospital and malpractice lawyers told us never to admit guilt. Risk managers were clear that we were to contact them in the event of an error. If patients’ families had questions, we were to be vague with our responses, essentially brushing them off.
Gradually, such attitudes and practices have been changing. First, policymakers, doctors and other providers have realized that medical errors are often systemic problems rather than incidental lapses. And error disclosures, once considered an ethical obligation to be treated as a problem only if a patient sued, are now being written into hospital policy.
In 2001, the organization that accredits hospitals developed national standards for a more coordinated approach to reporting errors and protecting patients, and from 2002 to 2005 the proportion of hospitals with disclosure policies doubled to 70 percent, according to a 2007 New England Journal of Medicine article. (A 2002 NEJM study had found that only one in three preventable medical errors was being disclosed to patients.) The national standards require that patients be informed of all outcomes of care, including “unanticipated outcomes.”
While this policy shift alerted physicians like me to a change in perspective, it did little to change our behavior. Many doctors were trained in an autocratic and sometimes patronizing culture, and there were few incentives or penalties to push change.
In 2006, a working group representing Harvard-affiliated hospitals established that a disclosure policy must include three elements: The provider must take responsibility, apologize and discuss preventive measures with the patient or the family.