In the health care industry, communication and transparency both play a large role in maintaining patient safety and ensuring management of clinical risk. In fact, about 70% of adverse events (AEs) can be traced back to gaps in communication.
“Many times we blame adverse events on an ill-defined process, the environment of care, lack of education, lack of training or equipment malfunction, but typically they stem from human error or lack of communication,” said Brian M. Parker, MD, an anesthesiologist at Cleveland Clinic in Ohio, and chairman of the Cleveland Clinic’s Medical Legal and Clinical Risk Management Committee. Dr. Parker discussed strategies for effective communication here at the American Society of Anesthesiologists’ Practice Management 2015 conference.
Before an AE occurs, physicians should avoid potential legal hiccups by maintaining accurate documentation. With electronic medical records, everything typed and saved in the record becomes the legal interpretation of the event. Providers must be accurate and detailed and state what was known at the time of the event. They should not speculate in the electronic record, and should not be part of the “blame game” in the chart, Dr. Parker said. Everything in the medical record can be used as potential evidence in a trial and for punitive damages, so disputable facts or sideline stories that can be turned into dramatic narratives should be avoided. If providers create a “late entry” in the medical record, they should clearly include the purpose of the entry and not alter or delete previous entries in the record. All of these small actions can change the way lawyers interpret the record of a patient’s care.
“Attorneys may look for audit trails and want to see what you looked at and when,” Dr. Parker said. “Everything has an electronic signature, so they can see if you actually looked at the EKG screen and for how long you looked at it.”
When a medical error or unanticipated outcome occurs, the next steps are the most vital. How the event is handled can determine the course of what happens—and whether that means litigation. About 80% of claims arise from poor communication, Dr. Parker said, and 70% of individuals who sue feel their questions about an AE were devalued or ignored. Apologies and disclosures are viable alternatives to the “deny and defend” tactic used for so long. But apologies and disclosures should be done in the context of the institution, the medical malpractice insurer and as part of a medical team.
The care team must create a communication plan—and do it together. They must prepare for the conversation with the family and patient; learn who will be present for the conversation; and determine what the family dynamics are. Team members must practice what they will say and how they will answer any questions. Anesthesiologists often are still dealing with critical situations when other physicians communicate with family members, but if possible, they should be there for that first discussion.
“This is your opportunity to go in with a unified front alongside the surgeon or physician,” Dr. Parker said. “Don’t let someone else represent the care you rendered. It’s better to know what’s being said about you and how the family was told.”
In Ohio and 35 other states, physicians can say “I’m sorry” when disclosing events with patients. Evidence shows that multiple institutions have been successful at using an “I’m sorry” approach, Dr. Parker said, but only in the context of rigorous risk management programs. Disclosures can lead to reduced costs per claim, fair settlement negotiations and emotional benefits for patients and caregivers. At the Cleveland Clinic, risk managers use a “just in time” coaching approach to prepare physicians for a disclosure conversation.
“What makes a good disclosure? Planning. I can’t say it enough,” Dr. Parker said. “Identify the best time, setting and people to participate.”
During a disclosure conversation, patients need accurate information, emotional support and a specific follow-up. They want to know how providers will prevent the medical error from happening again. A study in Colorado from 2007 to 2009 tracked responses to 837 AE disclosures through 445 patient surveys and 705 physician surveys. Overall, the doctors rated themselves well, but patient ratings of physicians were scattered. Patients gave high marks to the physicians for being truthful, explaining the AE with clear terminology and offering an apology. However, patients felt the physicians did not tell them as much as they wanted to know about the event, why the event happened and whether the event was preventable.
The top concern? The patients did not think the doctor assured them that steps would be taken to prevent similar events from happening in the future. “For many patients, the main concern really is about the institution sorting out the error and making sure it doesn’t happen to someone else,” Dr. Parker said. “How you handle an event often determines the course of what happens next.”