How physicians can create a culture of patient safety

AMA Leader Commentary. By Timothy T. Flaherty, MD. May 6, 2002.

AMA LEADER COMMENTARY

A few words about current events in medical practice

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A message to all physicians from Timothy T. Flaherty, MD, chair of the AMA Board of Trustees.

With so much attention being paid today to professional liability reform, any one of us might hesitate to admit that we have ever committed a medical error. But the truth is, accidents do happen, and the best way to handle them is to acknowledge them when they do occur, and use the opportunity to figure out how not to let them happen again.

We call this "creating a culture of safety," and it's at the heart of the National Patient Safety Foundation.

As physicians, we have an absolute obligation to inform patients when they have been harmed and not helped, even when that harm is not solely our responsibility. The AMA's Council on Ethical and Judicial Affairs makes it clear that as physicians, we have an ethical obligation to tell our patients when a significant error has occurred. That way, the patient can seek remedial care if needed. And can truly give informed consent to those remedies.

For those of you who might think that's a risky proposition, remember this: Research has shown that patients are less likely to sue physicians who tell them honestly that they have made a mistake. In fact, telling the truth and admitting error may even prevent lawsuits in some cases.

The story is told about the lawyer who was misdiagnosed for a liver condition. His doctor discovered the error and confessed, told his patient that he had pursued the wrong course of testing and, as a result, treatment for the condition would be delayed.

The doctor admitted he had made a mistake. That wasn't easy to do, especially when the patient was an attorney. But the lawyer responded in a way we might not expect. "That's OK, Doc," he said. "You can't think of everything."

Not every patient will forgo a lawsuit. But if our ethical obligation is first, to do no harm, then we need to be forthcoming. We need to tell our patients for their own well-being when an error has been made. Because to do anything else would be an outright violation of the trust on which our relationships with our patients is founded.

We are all affected when professional liability rates skyrocket. But the very foundation of our profession is shaken when someone who has made a medical error shirks from telling the truth about it.

As many of you are aware, the AMA founded the National Patient Safety Foundation six years ago in partnership with CNA HealthPro and 3M and with contributions from the Schering-Plough Corp.

An independent, nonprofit research and education organization, the NPSF brings together many segments of the health care industry, including physicians, who are committed to making America's health care safer for our patients.

I take pride in serving as the vice chair of the NPSF's Board of Directors. By the time you read this, I will have participated in the NPSF Annenberg IV conference, Patient Safety: Let's Get Practical, April 22-24 in Indianapolis.

The keynote speaker at Annenberg IV is Charles Vincent, professor of psychology at University College London (England), who is known for his work in human factors thinking and the psychology of error. He proposes that to make effective safety interventions, we need to look at people's skills, memory and decision-making abilities to understand error.

Another highlight of the program is the overview of the more than 60 candidate safe practices currently going through the National Quality Forum consensus process to be included in their compendium of Evidence-Based Practices for Safer Health Care.

I will be speaking on an expert panel, called And the Final Answer Is ..., which wraps up the conference and answers any questions conference participants may have before they return home to apply the solutions they've learned.

The panel is moderated by William R. Hendee, PhD, of the Medical College of Wisconsin in Milwaukee. My fellow panelists are James Bagian, MD, VHA National Center for Patient Safety; Connie Crowley Ganser, RNC, Children's Hospital, Boston; Roxanne Goeltz, Partner in Health Care; Carol Ley, MD, MPH, National Patient Safety Foundation; and John Noble, MD, Joint Commission on Accreditation of Healthcare Organizations.

At the time of this writing, I can't tell you what questions will be thrown at us, because the conference hasn't happened yet, but I can tell you that patient safety is a concern at every level of health care, from the administrative to the staff level, and, increasingly at the patient level.

I expect questions like, "How do we develop a process to make sure that a certain error never happens again?" and "Do you really think we should admit when we're wrong?" I hope I get that second question. Because I've got the answer all ready.

Dr. Flaherty, a board certified radiologist from Neenah, Wis., was AMA board chair during 2001-02.