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Spotlight Case June 2004


This presentation is based on the June 2004. AHRQ WebM&M ... A 10-year-old child from India presented to his pediatrician's office for a school physical. ... – PowerPoint PPT presentation

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Title: Spotlight Case June 2004

Spotlight Case June 2004
  • The Wrong Shot
  • Error Disclosure

Source and Credits
  • This presentation is based on the June 2004 AHRQ
    WebMM Spotlight Case in Pediatrics
  • CME credit is available through the Web site
  • See the full article at http//
  • Commentary by Thomas H. Gallagher, MD,
    University of Washington Wendy Levinson, MD,
    University of Toronto
  • Editor, AHRQ WebMM Robert Wachter, MD
  • Spotlight Editor Tracy Minichiello, MD
  • Managing Editor Erin Hartman, MS

  • At the conclusion of this educational activity,
    participants should be able to
  • Describe the rationale for disclosing harmful
    errors to patients
  • Appreciate the features of disclosure considered
    most important to patients
  • Define the disclosure gap
  • Recognize the emotional impact that errors have
    on health care workers
  • List specific steps that institutions can take to
    enhance the disclosure of harmful errors to

Case The Wrong Shot
  • A 10-year-old child from India presented to his
    pediatricians office for a school physical. The
    child had no past medical history all
    immunizations were up to date with the exception
    of Hepatitis B. The physician discussed
    vaccination with the patients father and
    obtained consent. The nurse drew up the vaccine
    and the physician administered it. After
    administration, the physician went to record the
    lot number and discovered that vaccine for
    Hepatitis A had been given instead of Hepatitis B.

Frequency of Adverse Drug Events
  • Adverse drug events (ADE) are common in both
    inpatient and outpatient setting
  • In hospitalized patients up to 6.5 of patients
    have ADE up to 25 of these preventable
  • In outpatient setting over 25 have experienced
    ADE, 40 of which were ameliorable or preventable

Bates DW, et al. JAMA. 19982801311-6 Gandhi
TK, et al. N Engl J Med. 20033481556-64.
Disclosure of Medical Errors
  • Increasingly, hospital boards and regulatory
    agencies are requiring disclosure of
    unanticipated outcomes
  • Actual disclosure of events and discussion of
    details is uncommon
  • Only 1/3 of patients surveyed who had experienced
    a medical error said health care professional had
    disclosed error or apologized

Blendon RJ, et al. N Engl J Med. 20023471933-40.
Disclosure What Patients Want
  • Jargon-free statement that error occurred
  • Description of the error and why it happened
  • Implications of the error for their health and
    how to deal with the consequences
  • Outline of steps that will be taken to prevent
    future errors
  • An apology from the health care worker

Gallagher TH, et al. JAMA. 20032891001-7.
Barriers to Disclosure for Physicians
  • Fear of litigation
  • Unlikely to apologize due to concern about
    consequences of admitting fault
  • Discomfort with discussing such issues
  • Physician may choose words carefully to avoid
    explicitly stating that an error occurred
  • Concern that information may harm patient
  • Belief that disclosure may impact patients trust
    in the physician

Gallagher TH, et al. JAMA. 20032891001-7
Robinson AR, et al. Arch Intern Med.
20021622186-90 Wu AW, et al. JAMA.
The Disclosure Gap
  • Disclosure gapmismatch between recommendations
    that all harmful errors be disclosed and the
    evidence that, in practice, disclosure is
    uncommon. Reasons
  • Physicians believe disclosure is the right thing
    to do, but encounter insurmountable obstacles or
  • Physicians unclear about whether and how to
    disclose errors

Case (cont.) The Wrong Shot
  • Without hesitation, the physician informed the
    father that the the boy had received the wrong
    vaccine. He explained the usual indications for
    Hepatitis A vaccination and emphasized that this
    vaccine would not harm the boy and may protect
    him from future illness. He suggested that the
    boy still receive the Hepatitis B vaccine. The
    father became extremely angry, refused to allow
    further vaccination, and reported the incident to
    the clinic administrator.

Improving Disclosure Outcome
  • Approach disclosure as integral component of
    quality improvement
  • Employ empathic communication techniques
  • Work closely with risk managers throughout
    disclosure process

Disclosure and Malpractice Litigation
  • Some argue that skillful disclosure will lessen
    malpractice claims
  • Others argue that the reason few injured patients
    sue is because they are unaware error occurred
  • Physicians are unlikely to willfully contribute
    to increasing malpractice suits
  • Disincentives include soaring malpractice
    premiums and reporting requirements
  • Wholesale tort reform and transition to no-fault
    malpractice system would facilitate full
    disclosure of medical errors

Kachalia A, et al. Jt Comm J Qual Saf.
200329503-11 Levinson W, et al. JAMA.
1997277553-9 Vincent C, et al. Lancet.
19943431609-13 Studdert DM, et al. N Engl J
Med. 2004350283-92.
Case (cont.) The Wrong Shot
  • After the incident, the physician in this case
    felt responsible for the loss of trust and the
    missed opportunity to administer an important
    vaccine to a child.

Impact of Medical Errors on Physicians
  • Physicians frequently feel powerful emotions
    following medical error
  • Disappointment about failing to practice medicine
    to their own standards
  • May include physical symptoms such as insomnia,
    anxiety, difficulty concentrating
  • Physicians may fail to disclose errors due to
    embarrassment, guilt, or fear of litigation

Gallagher TH, et al. JAMA. 20032891001-7
Levinson W, et al. JAMA. 19892612252
Christensen JF, et al. J Gen Intern Med.
19927424-31 Newman MC. Arch Fam Med.
Institutional Interventions to Improve Error
  • Provide emotional support to clinicians as
    component of patient safety program
  • Offer communication skills training
  • Standardized patients, role-playing
  • Educate physicians about causes and prevention of
  • Dispel myth that fault usually lies with the

Take-Home Points
  • Harmful errors should be disclosed to patients
  • Error disclosure should include an explicit
    statement that an error occurred, a review of the
    cause, plans for prevention, and an apology
  • Physicians should seek help from institutional
    risk managers prior to discussions

Take-Home Points
  • The link between error disclosure and quality
    improvement should be emphasized
  • Institutions should provide communication skills
    training and support programs that facilitate
    error disclosure
  • Further research is needed to examine the
    relationship between disclosure and malpractice