Researchers advise medical care groups to report multiple medical errors

GHN News - As medical errors continue to rise, there are recommendations from researchers to help organizations make sure those errors involving multiple patients are disclosed.

The rate of medical error and type are more and more being disclosed to

patients even if they were not harmed by the event.  These events
include not using completely sterilized equipment, exhibiting poor
laboratory control, and equipment malfunctions that can impact the
patient.  The problem is there is not sufficient disclosure about
multiple incidents.

"It's clear that
health care organizations face a dilemma regarding disclosure of
large-scale adverse events – whether these events lead to patient harm
or not," said AHRQ Director Carolyn M. Clancy,
M.D. "It's not always clear how to do that in a way that minimizes risk
to the patient and the organization, but this research can help."

According to researchers from the University of Washington, Seattle,
hospitals and medical centers are reluctant to disclose problems that
have affected many patients.  There are concerns about the psychological
implications in doing so, but the researchers conclude that in most
cases these events should be disclosed.

These are the recommendations offered on how to make those disclosures:

• "Develop an institutional policy.
  Organizations should have a clear set of procedures for managing the
  disclosure process, notifying patients and the public, coordinating
  follow-up diagnostic testing and treatment and responding to regulatory
  bodies.


• Plan for disclosures.
  Disclosures should be made proactively, unless a strong, ethically
  justifiable argument can be made not to do so. The method of disclosure
  may depend on the event, but patients should be informed personally and
  all at the same time.


• Communicate with the public.
  Organizations should assume that media coverage of a large-scale
  adverse event is inevitable. To build public trust, media responses
  should demonstrate the organization's commitment to honesty and
  transparency.


• Plan for patient follow-up.
  Organizations should provide follow-up diagnostic testing and treatment
  to patients affected by the LSAE and address any anxiety caused by the
  disclosure. Patients who have suffered physical harm due to an event
  resulting from a preventable error or system failure should be
  compensated."

Lead  author Denise Dudzinski, Ph.D., an associate professor in the Department of Bioethics & Humanities at the University of Washington explains it is important to have the public trust, which is an essential reason for full disclosure.

"These
disclosures are never easy, but it is critical that organizations invest
the time and resources necessary to learn how to handle these
disclosures effectively,"  concludes researchers.