When patients are harmed by medical care, the traditional response of health systems is to “deny and defend.”
Hospitals deny they are responsible for the harm, and when pressed, they defend their providers’ conduct throughout a protracted and arduous legal process. According to a recent issue of the Journal of the American Medical Association, hospital administrators say that this approach minimizes their liability.
Sometimes, when errors are egregious or there is intense media scrutiny, as in the case of the misdiagnosis and death of Texas Ebola patient Thomas Eric Duncan, hospitals eventually apologize and make financial settlements. But without media attention, routine harm resulting from errors still typically receives the “deny and defend” response.
Such behavior has failed to make the U.S. health care system safer or more humane for patients and families. The good news is better alternatives may now be available.
This past week’s announcement of President Barack Obama seeking $6.2 billion for Ebola-related funds from Congress — including $2.4 million for the U.S. Department of Health and Human Services — demonstrates that many feel the Ebola crisis will likely continue to stress the US healthcare system. In doing so, the situation will reveal many of its flaws and weaknesses.
Every day in every hospital in America, health professionals make mistakes that harm patients. The frequently cited estimate from the Institute of Medicine’s 1999 report on medical error was that 98,000 Americans die each year from medical errors. A 2013 estimate from the Journal of Patient Safety put the number of deaths due to preventable harm at 400,000, with perhaps 10-20 times more people being seriously but not fatally harmed.
From the perspective of patients and families, the typical hospital response prevents access to the truth. It also denies them a chance to tell their stories, denies them an apology when they deserve one, and denies them an opportunity to reach rapid and equitable out of court settlements.
Such an approach is anathema to learning and improving. It promotes secrecy about the individual and systemic causes of medical errors and substandard care, makes it impossible to identify and learn from patterns of error, and leaves us defenseless against present and looming health threats.
A 2010 study in the New England Journal of Medicine showed that American hospitals are not getting safer, and one of the main obstacles to improvement is the lack of transparency promoted by this “deny and defend” mindset.
Dr. Craig Spencer’s release recently from New York’s Bellevue Hospital, after he was declared Ebola-free, was in part because he was rapidly and correctly diagnosed. Perhaps it is because of the eventual candor of Texas Health Presbyterian Hospital Dallas and the death of Duncan that other hospitals and doctors were able to learn from their mistakes.
It appears that miscommunication and other routine mistakes led to Duncan being misdiagnosed, and delayed his receipt of proper medical care by three days. After the misdiagnosis, the Texas Health Presbyterian Hospital Dallas denied any wrongdoing, delaying the process by which other hospitals could learn from its mistakes.
Facing intense media scrutiny and negative publicity after two nurses who had treated Duncan were diagnosed with Ebola, the hospital hired a public relations firm and published an open letter, admitting some of its mistakes and apologizing.
In the wake of his death, Duncan’s family had publicly expressed pain and frustration at the hospital’s lack of transparency, cooperation, and compassion. The shift to apology, financial reparations, an undisclosed sum and a charity in Duncan’s name, mark a clear tactical shift.
Sadly, the Duncan family’s initial experience is not unusual.
In our research on communication and resolution approaches to malpractice, patients and families who have been victims of medical errors tell us that without hearing an explanation or apology, every hour that passes after the initial harm event feels like an additional injury.
Fortunately, there is now a viable alternative.
Several hospitals around the country, notably the University of Michigan and the University of Illinois at Chicago, have adopted the so-called communication and resolution approach to unexpected patient harm.
This approach emphasizes rapid reporting of harm events, rapid communication with patients and families, and rapid investigations to identify possible system failures and to determine whether or not the patient was harmed by inappropriate care.
When an investigation reveals inappropriate care, the health professionals who were involved meet with the patient and family, admit liability, describe in detail what happened, apologize and offer emotional support, and maintain contact for ongoing communications.
Depending on the nature and severity of the harm, the hospital will often waive fees and charges related to the care that caused the harm, waive fees for subsequent care to remedy the harm, and offer financial settlements to compensate patients and families for pain and suffering and for the cost of ongoing care — all without litigation.
Research shows that communication and resolution programs have many benefits. Those include fewer claims and lawsuits, increased reporting of near misses and errors, more rapid settlements for patients, lower malpractice insurance costs, lower legal fees and expenses for hospitals, and less defensive medicine being practiced by physicians.
More importantly, telling the truth to patients after they have been harmed by medical errors is the right thing to do. It is more just, equitable, and humane.
It is better for providers too, who are often traumatized by unintentionally harming the people they were trying to heal, and who are prevented from apologizing, and even speaking, to patients and families.
To minimize the risk of Ebola becoming pandemic in the U.S. and to improve on other errors, health systems must quickly learn from each other’s successes and failures. But this can only happen if there is transparency when things go wrong.
One of the advantages of a communication and resolution approach to medical error is that its openness facilitates data collection, learning, and process improvement.
Make no mistake — it is not enough to tell the truth to patients after we harm them. Our primary objective must be to harm fewer people by making health care safer. Although we do not always know precisely how to make care safer in the short term, we know it will require openness and transparency to support learning and process improvement.
Until the day comes when we eliminate harmful medical errors, we should create systems that respond as humanely and constructively as possible after harm occurs.
Communication and resolution programs offer a concrete alternative to the more common approach that inhibits learning, pours salt in the wounds of patients and families by stonewalling, billing for harmful procedures, and even ruining patients’ credit by sending them to collections when they refuse to pay for care that hurt them.
An open and transparent response to harm also enables healthcare systems to rapidly adapt to emerging threats like Ebola.
“Deny and defend” has become an indefensible approach to medical error. The time has come to abandon it.
Bruce L. Lambert, PhD, is Professor of Communication Studies and Director of the Center for Communication and Health at Northwestern University and part of the NU Public Voices Fellowship through The OpEd Project. Timothy B. McDonald, MD JD, is Chair of Anesthesiology and Medical Director for Quality and Safety, Sidra Medical and Research Center, Weill Cornell Medical College, Doha, Qatar, and Adjunct Professor, Beazley Institute for Health Law and Policy at Loyola University Chicago.
