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When something goes wrong…

Be it major or minor, healthcare providers will likely make a mistake somewhere in their career, whether they know it or not.

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Healthcare providers wish they could be perfect all the time and never commit an error involving a patient. Unfortunately, that’s not reality. Mistakes can and do happen at every level of the healthcare continuum.

Human beings deliver medical services, so errors are inevitable. Be it major or minor, healthcare providers will likely make a mistake somewhere in their career, whether they know it or not.
When something goes wrong, the main question is whether damage or loss occurs as a result. Here’s the other question. What do people do when they see a mistake or inappropriate behavior occurring in others and in themselves?

Recent studies have indicated that cultures of silence are the norm. A considerable amount of error goes unreported. It is estimated that only 25 percent of medication errors are reported.

Adverse drug-related events are common in both the inpatient and the outpatient settings. Studies of hospitalized patients find that up to 6.5 percent had an adverse drug event and about 25 percent of those were preventable. While less is known about adverse drug events in outpatients, a recent study demonstrated that over 25 percent of outpatients had experienced a recent adverse drug event, with 40 percent of those being preventable.

When a harmful error takes place, patients first want an explicit, not evasive, statement that an error occurred, what the error was and why it happened. Second, patients want to understand the implications of the error for their health their care team will deal with the consequences. Third, patients want to know how the doctor, nurses, other healthcare workers and the healthcare system will learn from this error. Fourth, patients want an apology.

However, healthcare workers may hesitate to provide such information to patients. Studies of physicians’ attitudes have identified several barriers to disclosure, such as fear of litigation or media attention.

These barriers can lead physicians to “choose their words carefully” when talking to patients, mentioning the adverse event but avoiding explicitly saying that an error occurred. Physicians think about whether to take personal responsibility for an error, or point the error to a breakdown in the system of care.

This mismatch between recommendations that all harmful errors be disclosed to patients and the evidence that, in practice, such disclosure is uncommon, has two potential interpretations.
Clinicians may appreciate that error disclosure is “the right thing to do” but experience insurmountable obstacles in their attempts to tell patients about errors.

Alternatively, this disclosure gap may reflect certain complexities in the decision about whether and how to disclose errors to patients. Little is known about whether disclosure of errors that cause minor harm or disclosure of near misses is desirable from either patients’ or physicians’ perspectives.

During my years in patient experience management, I was part of the Risk Management Committee which studied cases across the globe that resulted in serious adverse outcomes.

It is, indeed, a challenge to reveal the medical error and there are diverse factors that affect a physician/nurse or healthcare worker’s readiness to disclose errors. But beyond a duty to the patient or the hospital, every member of the care team has a responsibility to practice responsible and honest medicine, with empathy to the patient and family and with a commitment to improve processes and systems to prevent future errors.

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With over 30 years of experience in patient care, healthcare marketing, business development and hospital operations, Marilen Tronqued-Lagniton is a Certified Lead Auditor for ISO 9001:2015. She earned a Bachelor of Science in Psychology from St. Theresa’s College in QC, Philippines; completed the MBA for Healthcare Administrators at the Anderson Graduate School of Management at UCLA; Completed the Patient Safety Officer Course, Institute for Healthcare Improvement (IHI) & Harvard School of Public Health (T.H. Chan) in Cambridge, MA; Completed the Advanced Leadership Program for C-Suite Leaders, Kellogg School of Management, Northwestern University (Evanston, IL). Email: mtlagniton@gmail.com

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