Do Wrong to None
In this new era of value-based health care, radiologists believe that reporting errors will bolster patient trust.
"Deny and defend.” For many years, this was the credo of risk managers, quality improvement experts, and radiologists alike when an error was committed during the course of a patient’s care.
Myriad factors played into this defensive posture, including fear of protracted malpractice lawsuits within a dysfunctional tort system, trepidation over diminished standing among colleagues, and, at worst, a loss of one’s license to practice medicine. But over the past 20 years, radiologists have begun to see the advantages of disclosing errors to patients.
A new vanguard of radiologists believes that, as Patient Protection and Affordable Care Act mandates begin to take effect, it is becoming critically important to divulge errors to internal quality assurance and risk management departments as well as to patients. They argue that doing so is not only the right thing to do, but that admitting fallibility will provide patients with a fuller picture of the state of their health, thereby building a bond of trust between doctor and patient.
Roots of Change
Many radiologists point to the work of Lucian L. Leape, MD, health policy analyst at Harvard’s School of Public Health, as the beginning of the sea change in the perception of error reporting. An advocate for the non-punitive approach to remediating medical errors, Leape postulated in a landmark 1994 article that, if disparate studies of the number of errors that at least in part led to patient deaths were extrapolated across the US, it would amount to a mortality rate of 180,000 per year. This number would equal, as he put it, “three jumbo-jet crashes every two days.”1
Leape posited that the logic regarding medical errors — that well-trained physicians should not make mistakes, and that punitive measures would deter those who did from repeating them — was faulty. He argued that this shaming tactic caused health care professionals to avoid reporting adverse events all together. Furthermore, since errors were rarely the result of misconduct and “almost always caused by systems failures … not under the control of the individual who makes the error,” this punitive approach did not improve patient care.2 Instead of denying the existence of mistakes, he asserted, doctors should examine how tactics employed by other industries with positive safety records could be adapted to the field of medicine.
Statements from organizations like the AMA, the Joint Commission, and the American Congress of Obstetricians and Gynecologists (ACOG) have echoed this urgent need to disclose adverse events to the patient. ACOG’s language on the matter highlights this value-added dynamic, stating, “Improving the disclosure process through education, policies, programmatic training, and accessible resources will enhance patient satisfaction, strengthen the physician–patient relationship, reduce physician stress, and, most importantly, promote safe and high-quality health care.”3
Breakdown in the Process
Although large medical organizations have weighed in on the moral imperative of reporting adverse events to patients, some radiologists still shy away from disclosing mistakes. The process for divulging errors often involves first reporting the error to a risk management department and then explaining the error to the patient. And it can be confusing. According to Stephen D. Brown, MD, assistant professor of radiology at Boston Children’s Hospital and Harvard Medical School, lack of radiologist compliance can be traced to several causes. “Radiologists are fearful of losing their professional standing,” he explains. “They also may not want to make their colleagues look bad.” In addition, they may not understand how the process works. “Their departments or institutions may not have mechanisms for supporting such an initiative. Also, they may not know when it’s appropriate to report an error or even what constitutes an error,” says Brown.
In addition, it may not be immediately obvious who should take ownership of the transgression. Leonard Berlin, MD, FACR, radiologist at Skokie Hospital in Skokie, Ill., and professor of radiology at Rush University and the University of Illinois, both in Chicago, says that radiologists should consider the insurance complexities that exist in their institution before divulging an error to a patient. “It’s very important for radiologists to check into their malpractice insurance,” he says. “If they practice in an academic institution where they’re covered by the institution’s insurance, they should get a risk manager to accompany them when they report an error to a patient.” A private hospital, however, can be a different story. “A radiologist might be insured by company A, whereas the hospital is covered by company B and the attending physician is covered by company C,” says Berlin. In this situation, he notes, the radiologist needs to call the insurance company to get advice on how to approach the patient. “Sometimes clauses say an insured physician can’t speak on behalf of the insurance company and an admission of error could jeopardize the defense of the case for the insurance company,” says Berlin. In these cases, radiologists need to report errors to the insurer first.
For the radiologist who can navigate these challenges successfully, rewards await. Chief among these, many believe, is strengthening the patient-radiologist bond. Sarwat Hussain, MD, FACR, professor of radiology at the University of Massachusetts Memorial Health Care, says that radiologists need to stay focused on giving patients the fullest possible picture of their health care, which may include communicating adver
se events. “The changing paradigm of physicians admitting mistakes to patients and families is a step in the right direction,” he states. “I believe that the patient-physician relationship must be based on complete transparency and absolute honesty. These attributes should be employed wisely, keeping the best interest of the patient and the institution in focus.”
"Radiologists are fearful of losing their professional standing. They also may not want their colleagues to look bad." - Stephen D. Brown, MD
Incetivizing Error Reporting
While disclosing adverse events may be ethically correct, that fact alone may not be enough to motivate physicians to report them. In an effort to overcome the stigma associated with admitting fault, several institutions have devised ways to shine a positive light on error reporting. One such program is run by the department of radiation oncology at the University of North Carolina at Chapel Hill. The department’s “Good Catch” program, which seeks to encourage employees to divulge errors whenever they occur, has experienced a high level of success in its second year of existence.
Robert Adams, EdD, assistant professor in the clinical division of the University of North Carolina’s radiation oncology department, notes that the program came about when the chair of the department decided it was time to change people’s thinking about errors. They began by studying the airline and automobile industries to see how leaders in these areas mitigated inefficiencies. In the Good Catch program, “If employees catch an error, whether it’s large or small, they go online and fill out an error report,” Adams explains. Once the report has been submitted, a quality assurance representative investigates the error, beginning with the person who reported it. “A lot of times we find out that the error wasn’t caused by the person who committed it. You find out that something happened upstream to cause it, that there was a problem seven steps back,” says Adams.
The key component of the program is that it takes a non-punitive approach to the process. “Once the report is turned in, there’s no punishment associated with it,” says Adams. “In the past 16 months, we’ve investigated 290 of these cases, and they help us examine faults in the system.” From there, the department can strategically improve. Once a group within the department has submitted a certain number of good catches, the department pays for a speaker to come in to provide the employees with continuing education courses.
Opportunities for incentivizing error reporting abound, according to Syed F. Zaidi, MD, president and CEO of Radiology Associates of Canton Inc. in Canton, Ohio: “For example, improvement in the rate of biopsies that are non-diagnostic — which could be seen as an error — can be incentivized. I would incentivize improvements in the rate of non-diagnostic biopsies by improving biopsy protocols and techniques. Also, the rate of RADPEERTM entries can be tracked and incentivized so that that the amount of time radiologists spend doing quality improvement is paid for.” Further, he states, “There can be an extra incentive for reporting higher-level errors on the RADPEER scale of category 1-4. Call it a whistleblower payment. Except that there’s no political pushback because it should be tracked anonymously through RADPEER.”
Given the stakes involved in reporting errors, it is no wonder radiologists often feel conflicted about the best course of action. But when looked at in the proper light, disclosing adverse events can be seen as a positive tool for improving patient care. In a time when re-establishing a direct relationship with patients is a top priority for radiologists, error communication can form a bond of trust.
By Chris Hobson
1. Leape L. “Error in Medicine.” JAMA 1994;272(23):1851–57. Available at http://bit.ly/Leape. Accessed Oct. 21, 2013.
2. Mullen P. “A Conversation with Lucian Leape, M.D.: Moving Beyond a Punitive Mind-Set.” Managed Care. Available at http://bit.ly/LLeape Accessed Oct. 22, 2013.
3. The American Congress of Obstetricians and Gynecologists. “Disclosure and Discussion of Adverse Events.” Available at http://bit.ly/ACRACOG. Accessed Oct. 22, 2013.