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August 20th, 2007 NEWSLETTER - SPECIAL SW! NEWSLETTER
Doug Wojcieszak, Founder & Spokesperson
Contact phone/e-mail address: 618-559-8168;
doug@sorryworks.net
In lieu of our normal newsletter format, we are providing a special newsletter for our readers this week. Yesterday (Sunday), theChicago Tribune ran a front page story entitled, "Doctors try new word: Sorry." The story focused almost exclusively on the new but successful disclosure program at the University of Illinois Medical Center. In short, the story was a home run, and in the newspaper/public relations business it doesn't get any better than a Sunday front page story in one of America's premier newspapers. Sorry Works! was pleased to help with the development of this story.
We believe this story will spur many other hospitals & insurers in Chicago and Illinois to begin implementing disclosure programs. We also believe it will have a major impact nationally.
The Tribune story is below, and below the Tribune story is an excerpt from a June Sorry Works! newsletter which featured the University of Illinois Medical Center's new disclosure program.
We hope you find this special newsletter useful & exciting and hope you share it with your colleagues and friends.
Chicagotribune.com
Doctors try new word: Sorry.
Admitting mistakes not just right thing to do, medical community finds it may prevent malpractice suits
By Judith Graham
Tribune staff reporter
August 19, 2007
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."
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, jegraham@tribune.com
Directly below is the excerpt taken from the June 25th Sorry Works! newsletter concerning the University of Illinois Medical Center Disclosure Program.
NEW DISCLOSURE PROGRAM AT UNIVERSITY OF ILLINOIS MEDICAL CENTER IN CHICAGO (June 25, 2007 SW! Newsletter)
Back in March (2007), the University of Illinois Medical Center's Assistant Chief Medical Officer made a presentation on their new disclosure program at the Chicago Patient Safety Forum's Annual Meeting. Sorry Works! recently received a copy of the tape and we were very impressed with the presentation.
First, before we provide a summary of the presentation, a big tip of the hat is in order to the Chicago Patient Safety Forum (CPSF). Lenny Lamkin, Steve Maxwell, and the entire CPSF team have done outstanding work promoting and supporting disclosure and apology. The disclosure movement owes them a debt of gratitude. Here's why we are in their debt: Two years ago disclosure was not the hot topic it is today - it was controversial, at best - and The Sorry Works! Coalition was a brand new organization with more detractors than supporters, especially in our home state of Illinois. Nevertheless, CPSF Director Lenny Lamkin took a chance on Sorry Works! and disclosure by hosting a panel discussion on the issue. He took some static from folks around the state, but Lenny persisted in inviting Rick Boothman from the University of Michigan, Dr. Steve Kraman, retired Lexington VA Chief of Staff, and Doug Wojcieszak, Sorry Works! founder and spokesperson to provide a panel discussion for the CPSF 2005 Annual Conference. The room was packed with staff from Chicago-area hospitals. One of those people in attendance was Dr. Tim McDonald of the University of Illinois Medical Center in Chicago. The presentations excited Dr. McDonald, especially Boothman's talk. Dr. McDonald and his team soon visited the University of Michigan Hospital System - the most successful and best publicized disclosure program in the United States - and learned about their program. In his March 2007 talk, Dr. McDonald shared experiences from the first year of the UI program. It's a fantastic story, as you will read below.
We are proud to report that many other Chicago-area hospitals present at the 2005 CPSF disclosure panel are also developing disclosure programs, and we hope to share their success stories soon. So, a big tip of the hat to the Chicago Patient Safety Forum (www.chicagopatientsafety.org). By taking a chance, the CPSF folks greatly advanced the cause of disclosure and apology and we owe them many, many thanks. Furthermore, we hope other organizations follow the example set forth by the Chicago Patient Safety Forum.
Now, on to the report. As discussed earlier, Sorry Works! has reviewed a taped copy of Dr. McDonald's presentation. Fantastic presentation and Dr. McDonald shares a lot of the same passion and enthusiasm for the topic exhibited by other leaders in the field.
What follows are several observations about the UI program, some of which are new and different for disclosure programs:
- The University of Illinois Medical Center went from a hospital that practiced "deny and defend" to today where their goal is to investigate, apologize, settle or mediate, and learn from mistakes in 60 days or less. Speed is one of the hallmarks of this program. Dr. McDonald emphasized that they try to complete most investigations in 72 hours or less. They have a real system in place to move fast when adverse events happen so they quickly collect the information, figure out what happened, and work with the patient/family.
- In one year of conducting the program, UI has had 40 disclosures but only one claim! Remember, this is Cook County, Illinois, which the American Tort Reform Association considers to be the 2nd worst judicial hellhole in the United States. Conventional wisdom would counsel "shut up and don't say a thing," but they have done the exact opposite at the UI over the last year and the results have been very impressive.
- In establishing their program, UI program leaders got buy-in from all sectors of their system, including high-risk specialities, administration, guest services, PR folks, the Board of Trustees, and the University President, Joe White. President White was actually a pretty easy sell because he was at the University of Michigan when they implemented their disclosure program.
- The biggest barriers UI faced was outside defense counsel. Dr. McDonald shared a story that when they were starting their disclosure program the medical center was also interviewing for new outside counsel. During interviews, a question was posed to the prospective attorneys how they would handle a surgery where the wrong leg was removed. Twelve of the 16 firms counseled deny and defend, and one even advocated altering the medical record to imply that the "wrong leg" needed to be removed anyway! Amazing. Dr. McDonald said you have to find defense counsel who will accept litigating cases before the courts only on damages.
- Dr. McDonald said insurers can be an issue too; however, with UI they are self-insured for the first $15 million. Insurers are indeed an issue, but we hope - for example - that ISMIE Insurance (the dominant doctor mutual in Illinois) pays close attention to the UI experience. If UI can make it work in Cook County, it can work anywhere...it's just a matter of making it happen, and doctors and hospitals are anxious to try it. UI has shown that disclosure can work in Cook County (and elsewhere), so it's just a matter of ISMIE working with their insureds and local hospitals to develop a program, which is very doable. Doctors and hospitals want to do disclosure. UI has figured out that anger - not greed - drives most med-mal lawsuits, and if you have good customer service with excellent communication and problem solving techniques after adverse events, litigation will be reduced. Hopefully ISMIE and other insurers will figure it out too.
- Again, one claim in 40 disclosures. Tremendous savings on individual cases by investigating, apologizing, and fixing problems in a swift, fair fashion. "Fixes" involve waiving bills, child care expenses, lost wages, and, yes, even writing checks.
- Dr. McDonald shared several moving stories, including an event where a patient was given a massive overdose of cancer-fighting drugs. The patient was in excruiating pain and bleeding everywhere. The providers sat on the incident for a few days and felt horrible. Some providers became physicially ill, while others couldn't sleep. However, McDonald's team learned about the event, investigated quickly, and organized a disclosure meeting. The patient couldn't believe the honesty and candor. She was so glad to hear that she wouldn't be sick anymore, and that the problem was not with her. Furthermore, she was pleased the mistake was identified and corrected so it wouldn't happen to someone else. Finally, her bills were waived, which pleased her too. As for the providers, they got a huge load of their chest and felt so much better afterwards. It's all about healing!
- UI has a rapid investigation team as well as a error disclosure team trained in communicating with patients and families after adverse events.
- Billing is part of the process - with one key stroke all billing is stopped to a patient/family after an adverse event. This is an important point because often a bill or collection notice sent to a patient or family can literally blow the lid off a situation.
- UI also have a patient liason to work with the patient/family constantly and make sure they never feel abandoned after the adverse event.
- Support services have been implemented for providers as well to help them after disclosure. Remember, medical errors produce two (2) victims, both of which need to be treated. UI is doing it.
- They have an anonmyous hotline to report adverse events to the risk team. This is especially helpful for lower level people to report.
- They have developed a robust review system that is non-punitive to discuss and learn from mistakes. Processes are improved and medicine is made better, which benefits everyone and further reduces risk!
Those are the highlights from the Univ. of Illinois presentation at the CPSF meeting. Quite a story and look forward to hearing more about UI's successes. We also hope this will spur other hospitals and insurers to action.
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