By Renie Schapiro
Milwaukee Journal Sentinel
November 20, 2005
No one likes to admit mistakes and for health providers who depend on our trust, it must be harder still.
Add to that the conventional wisdom that confessing to a patient is a gold-plated invitation to a malpractice suit, and it's no surprise that many mistakes have traditionally been swept under the rug.
Angry and anguished patients who suspect malpractice have had little recourse other than pursuing costly and unpredictable litigation to understand what happened, vent their outrage and perhaps get compensated. Only an estimated 2% of patients who may have been harmed go to the trouble.
But some remarkable changes have been taking place.
More and more hospitals and bioethicists are instructing providers to tell patients when an error has occurred - explain what happened, apologize or express regret and tell them what is being done to make sure it won't happen again. Compensation is sometimes being negotiated, avoiding the need for litigation.
Nineteen states - not including Wisconsin - have passed "apology laws" that allow doctors to say "I'm sorry" without it being used against them in malpractice suits.
This openness is seen not only as the right thing to do to maintain an honest doctor-patient relationship; it also reduces the worrisome number of preventable hospital errors. And some evidence suggests it actually reduces malpractice litigation.
"The culture of the hospital is changing from deny and defend to openness and transparency," says Doug Wojcieszak. After his brother died from a medical error, he founded "Sorry Works!", an Illinois-based coalition to promote a protocol for disclosure and apology at all hospitals.
The approach was tested in the Veterans Affairs Medical Center in Lexington, Ky.
There and in other hospitals, including the University of Michigan Health System, lawsuits dropped significantly.
At the Michigan hospitals, lawsuits and malpractice claims were cut almost in half between 2001 and 2004.
The drop in litigation does not surprise experts, who note that anger and poor communication are prime reasons patients sue.
More openness and a focus on patient needs reduce the motive for litigation.
Last month, the Veterans' Administration made it official policy that all its hospitals and providers are obligated to disclose adverse events to patients who have been harmed.
Some of Wisconsin's hospitals - including Froedtert and University of Wisconsin Hospitals and Clinics - have impressive programs to work with providers and patients to ensure effective disclosure. For the first time, UW medical students are being taught about disclosing.
Disclosure is also key to reducing mistakes - according to a 1999 Institute of Medicine report, as many as 98,000 people a year may die from preventable hospital errors. About two years after the report, the hospital accreditation agency JCAHO called for practitioners to disclose errors.
When mistakes are kept secret, they are less likely to be fixed and more likely to be repeated.
As the Urban Institute's Robert Berenson points out in an article last month in The New Republic, the current malpractice system perpetuates secrecy.
More than 90% of malpractice suits are dropped or settled out of court. Typically, documents are sealed and with them the information needed to prevent future errors.
Surveys show that patients overwhelmingly want to be informed when a mistake is made and told what is being done to keep it from happening again. Even though the disclosure can be emotionally difficult - for the patient and providers -experience shows that patients are grateful that the medical team has shared the facts and expressed regret.
"In general this is not something people leap to the table to do," says Robyn Shapiro, director of the Center for the Study of Bioethics at the Medical College of Wisconsin. "But in my experience, when disclosure occurs, the experience has never been negative."
Norman Jensen, vice chairman of the University Hospital ethics committee in Madison, has been interested in disclosure since 1976 when, as a young physician, he privately agonized over whether to tell a patient that he prescribed 10 times too high a dose of blood thinner. No one was talking about medical errors then, he recalls.
He told her and now he helps guides other doctors through the process. Some doctors' "near hysteria" about malpractice makes them resist disclosure, he says. But whether to disclose is not a serious debate. Now, he says, the attention is on how to do it well.
Renie Schapiro is a consultant to the University of Wisconsin Medical School and the Institute of Medicine. She can be reached at renieschapiro@hotmail.com.
Appeared in the Milwaukee Journal Sentinel on Nov. 21, 2005.
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