Doctors try new word: Sorry.

By Judith Graham | Tribune staff reporter
http://www.chicagotribune.com

The doctor walked into the hospital room with a discomforting mission. He was there to admit a medical mistake and apologize to his patient, a woman with breast cancer.

The staff had given her the same injection twice by accident, causing her white cell count to soar, said Dr. Divyesh Mehta, chief of oncology at the University of Illinois at Chicago Medical Center. He recommended she stay in the hospital an extra day or two.

“This is our responsibility, and we are very sorry for it,” Mehta said, recalling the conversation.

Not long ago, this encounter would have been almost unthinkable. Medical foul-ups were rarely discussed among physicians and almost never acknowledged to patients. Doctors were too proud, too afraid of malpractice lawsuits, too worried about losing face.

But the culture of secrecy in medicine is beginning to change, as leading patient safety organizations call for fuller disclosure of medical errors and some trend-setting hospitals decide an “honesty is best” policy will improve care.

Advocates say acknowledging medical errors can advance healing by defusing patients’ anger and easing physicians’ guilt, especially when accompanied by an apology. Some also contend the practice can cut back on malpractice lawsuits and payouts, though with the movement in its infancy it’s too soon to know for sure.

Supporters include influential industry groups such as the Joint Commission on Accreditation of Healthcare Organizations and the National Quality Forum, which now recommend all hospitals disclose serious “unanticipated outcomes” in medical care — bad things that shouldn’t have happened.

The Veterans Administration and hospitals affiliated with Harvard Medical School have gone further, urging staff to tell patients about errors, apologize and explain how they plan to prevent similar mistakes.

Chicago has become something of a center for the emerging “fess up” movement. The UIC Medical Center is nationally known for its comprehensive error disclosure program, and the university’s medical school has created a curriculum to train future doctors how to recognize and deal with mistakes.

“The goal is to maintain patients’ trust,” said Dr. Tim MacDonald, UIC’s associate chief medical officer for patient safety.

But significant barriers to saying “I’m sorry” remain. Many hospitals say they support disclosing errors but haven’t instituted comprehensive policies, O’Leary said.

And although virtually all doctors say they want to be honest, fewer than half actually reveal serious errors in practice, according to an August 2006 study in the Archives of Internal Medicine. “These are folks who were No. 1 in kindergarten,” said MacDonald. “They’re not used to admitting they did something wrong.”

When doctors operate as a team it may be especially difficult for one to step forward.

Dr. David Mayer, an anesthesiologist and assistant dean for curriculum at UIC’s medical school, tells of an experience in the mid-1980s at a Chicago teaching hospital. A young man had come in for a hernia repair, and a surgical resident made the initial incision on the wrong side. The error was discovered quickly and corrected.

When Mayer visited the patient later, the man mentioned the doctors had told him they saw something suspicious on that side, went in to check and found nothing wrong. “I’m lucky,” Mayer recalls the patient saying.

Mayer was surprised but just nodded his head. “No one had ever talked to me about what to do when things don’t go as planned,” he said.

One of the biggest obstacles to disclosure is the fear of lawsuits. More than 30 states, including Illinois, have passed “apology laws” that prevent expressions of regret from being used against physicians in court. But most lawyers are skeptical and insurance companies typically still insist that doctors break off all communication with patients or families after medical snafus occur.

The fear, of course, is that any admission of wrongdoing could make it easier for patients to advance lawsuits.

The reverse argument is that patients will be less inclined to sue if doctors are forthright and hospitals offer reasonable compensation for injuries. In fact, Sens. Barack Obama (D-Ill.) and Hillary Rodham Clinton (D-N.Y.) have proposed national legislation that promotes disclosure of errors as a way of easing the malpractice crisis.

Some anecdotal evidence supports that view. Since 2001, when the University of Michigan Health System started acknowledging medical mistakes and offering prompt settlements to injured patients, the number of pending malpractice claims has decreased by almost two-thirds, according to chief risk officer Richard Boothman.

But in a study published earlier this year, Harvard University researchers predicted that claims will proliferate as more patients become aware of errors. “Disclosure is the right thing to do,” the researchers wrote in the journal Health Affairs, but its spread is “likely to amplify malpractice litigation.”

Dr. Steven Kraman, who helped launch one of the first disclosure programs at the VA Medical Center in Lexington, Ky., is among those who believe the value of institutions learning from their mistakes outweighs the potential costs.

Kraman recalls the case of a middle-aged woman whose family was unaware that she had died from a medication error. “Our team asked, ‘Would we want to know the truth if this was our mother?’ and the answer was obvious,” he said.

The physician advised the daughters to bring an attorney to a meeting. “Your mother was quite sick; in trying to help her we gave her far too much medication,” Kraman recalls telling them. “No one did this intentionally, but we’ve caused you a loss and we feel we owe you an explanation and compensation.”

As the attorney’s jaw dropped, the daughters expressed gratitude at being told the truth. A financial settlement was negotiated, and the hospital made several changes to prevent similar errors.

UIC is committed to teaching the next generation of physicians how to deal with these situations; its medical school last fall became the first in the U.S. to incorporate patient safety instruction in all four years of training. The curriculum culminates in a two-week course on medical errors.

As part of the training, students watch videos of an instructor interacting with an actor playing a distraught woman whose sister has died of cancer that went undiagnosed for months. In one video, the instructor responds coldly, refusing to answer questions directly. In another, the instructor volunteers information and expresses empathy.

Students go through similar exercises in person.

At UIC’s medical center, a wide-ranging disclosure program began about a year ago and is now considered a national model by many experts.

When a patient suffers harm, a team of doctors, nurses, pharmacists and social workers is expected to investigate within 48 hours. If the team finds an error, doctors are to meet with the patient, explain what happened and apologize.

Offering financial assistance is part of the bargain. “The best way to approach this is to own up to the fact that an incident happened and ask what can we do to fix it and make the situation better,” said John DeNardo, UIC’s chief executive officer.

In the first year, the hospital acknowledged 40 errors, and only one resulted in a malpractice claim, officials report.

One of those patients was Pamela Cephas, who had a mastectomy in October after cancer recurred in her left breast.

At UIC earlier this year, Cephas was supposed to have an injection of neulasta, a medication designed to keep her white blood cell count up, after beginning a new round of chemotherapy with tamoxifen.

Things went wrong when Cephas received the injection at UIC’s oncology clinic, then went to the hospital because of severe pain chemotherapy was causing in her hands and feet. Cephas’ medical chart showed no record of the neulasta, and without discussing the matter with Cephas a resident ordered another shot.

Mehta, the head of oncology, learned of the double injection the next day, when someone from the hospital contacted the clinic. Before talking to Cephas, “I checked all the facts and I put myself in the shoes of the patient and asked myself what her concerns might be, so I could prepare truthful answers,” he said.

Cephas’ white blood cell count had soared, but the implications were unclear. While blood-cancer patients with high white-cell counts have experienced ruptured spleens, Mehta could find no research applicable to breast cancer.

Cephas, 49, a patient of Mehta’s for seven months, recalls being shocked. Then she wanted to know more. “I was like, how could you make a mistake like that? And am I going to be all right?”

But she wasn’t angry, Cephas said. “He admitted it, and you know that isn’t easy,” she said. “I’m glad he did it.”

So is Mehta, who credits UIC for providing leadership and support to doctors who want to do the right thing. “When something like this happens, you feel guilty, you feel angry, you feel terrible. So it’s a tremendous relief to be able to share the truth,” he said. “I don’t want a deception to come between me and my patient.”

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Story so poignant med classes weep

When Helen Haskell tells the story of her 15-year-old son to medical students at the University of Illinois Chicago campus, they weep.

Her son, Lewis Blackman, bled to death, in excruciating pain, of a perforated ulcer that doctors at a South Carolina hospital failed to diagnose. The ulcer is a known complication of Toradol, a painkilling medication they were administering after an elective surgery.

Haskell repeatedly called for help, but hospital staff told her Lewis was constipated and had gas pains because of the painkillers he was taking. The residents — physicians in training — who saw the boy didn’t order a routine blood test that could have flagged the bleeding. Haskell’s urgent requests to have a senior physician examine her son were ignored.

When hospital staff couldn’t get a blood pressure reading, they assumed the monitor was malfunctioning and spent more than two hours repeating the test.

After Lewis’ death from cardiac arrest, his physician — who was not the senior doctor on call that weekend — told Haskell and her husband “this is our fault” and cried when he heard what had happened.

Their reaction? “We felt better. He was an honest man,” said Haskell.

Since her son’s death, Haskell has founded Mothers Against Medical Error and the Medical University of South Carolina has dedicated a chair in patient safety to her son.

“Helen inspires me and reminds me of what can happen when we don’t listen to the alarms raised by patients and their families,” said Dr. John Shaefer, the anesthesiologist who currently holds that post.

Without disclosure of medical errors, “there’s no learning from mistakes in institutions and the same things happen over and over again,” Haskell said.

— Judith Graham
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