Health care's culture doesn't encourage doctors to report medical errors of colleagues; article says patients should come first

By Melissa Patrick
Kentucky Health News

Doctors are often aware of their colleagues' medical errors, but fail to report them because of a culture that does not support or encourage such actions, Marshall Allen writes for ProPublica, a non-profit, non-partisan journalism organization.

Medical errors are estimated to kill 400,000 people in U.S. hospitals each year according to an online article by John T. James in the Journal of Patient Safety, causing some to say that medical errors are one of the nation's leading causes of death, Allen reports.

According to a report from the U.S. Department of Health and Human Services, most health-care providers employ a philosophy of "deny and defend" when confronted with issues related to medical errors. Providers fear full disclosure will lead to more lawsuits, higher jury awards, higher insurance premiums, and the loss of reputation or coverage for the provider, the opposite is true, the HHS report says. It says honest and open communication helps to lessen malpractice costs.

The Department of Veterans Affairs Medical Center in Lexington has led the way in the move toward health-provider transparency. It has worked under a philosophy of full transparency and disclosure since 1987, requiring prompt reporting and investigation of medical errors and near misses, full investigation, full disclosure of investigation results to the patients and families who have been injured because of accidents and medical negligence, and expressions of apology and  fair remedy, including compensation for injuries, according to the HHS report.

Several years ago, Allen contacted a Las Vegas surgeon to follow up on hospital data that showed peers of this surgeon that had high rates of surgical injuries. Allen reported that before he could reveal the list of peers to the surgeon and request his services in the investigation, the surgeon shared stories of the many surgeries he and his partners did to "clean up" the mistakes of "the worst surgeons in town" and said "he did not need a database to tell him which surgeons made the most mistakes."

An article in the New England Journal of Medicine, ?Talking With Patients About Other Clinicians? Errors,? says that although there is a common belief that there is an ethical duty to inform patients who have been harmed by medical errors, physicians often do not.

The existing guidelines emphasize ethical duties related to self reporting when physicians make  errors, says the report, but offers little guidance about what to do when they discover someone else's mistake.

In a survey separate from the New England Journal of Medicine report, but led by the same main author, more than half of doctors said that in the previous year they had identified at least one error by a colleague.  Gallagher told Allen that the survey did not ask what the doctors did about it.

For the New England Journal report, Dr. Thomas Gallagher, an internist and professor at the University of Washington, led a team of 15 experts who identified possible reasons doctors stay silent about errors by their peers. One reason is the system of referrals on which doctors depend, Allen reports; if a physician "becomes known as a tattler" he or she will lose referrals, and thus suffer financially.

The report lists other reasons for not reporting colleagues' medical errors, such as lack of time to investigate, a culture that promotes loyalty and solidarity, concerns about harming one's institution or becoming involved in a medical malpractice case,  concerns about causing a colleague to face legal issues,risk of acquiring an unfavorable reputation with colleagues and issues related to cultural differences, gender, race and seniority.

The bottom line, Gallagher told Allen, is that "physicians are not learning from their errors and patients are not getting the information they need to receive proper treatment or compensation when the outcome is harmful."

Dr. Brant Mittler, a cardiologist who works as a medical malpractice attorney in Texas, told Allen that in almost four decades in medicine he often saw errors and stayed quiet because "there would have been hostility" if he had reported them. ?There?s not a culture where people care about feedback,? Mittler said. ?You figure that if you make them mad they?ll come after you in peer review and quality assurance. They?ll figure out a way to get back at you."

Gallagher told Allen, "The result of this culture is too much leniency toward mistakes."

The New England Journal article said that despite the challenges of disclosure, the patient comes first, and doctors should "explore, not ignore" a colleague's error, Allen notes.

Once an error is suspected, the report suggests, the doctor recognizing the error should find the facts, starting with a direct conversation with the physician who made the error so together they can decide how to inform the patient. The article also suggests that hospitals and other health-care institutions lead by supporting transparency.

Dr. David Mayer, vice president of quality and safety at Medstar Health, which runs 10 hospitals in Maryland and Washington, D.C., told Allen that "reporting of medical errors (and near misses) is a top priority at the organization so everyone can learn from mistakes, saying that each month there are about 1,400 reported safety events."

The safety events are analyzed for trends, Mayer told Allen.  If a patient is harmed, an investigation is conducted and the information is disclosed to the patient and family, an apology can be made and compensation can be offered.

Dr. Humayun Chaudhry, president and CEO of the Federation of State Medical Boards, which provides guidance for how state boards regulate doctors, told Allen that doctors and other providers should be more assertive about reporting errors. "Failing to tell a patient about another doctor's mistake undermines the doctor-patient relationship," Chaudhry told Allen. "It makes patients wonder if they can trust their own physicians and the profession of medicine."

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