Welcome to the Clinical Center Grand Rounds, a weekly series of educational lectures for physicians and health care professionals broadcast from the Clinical Center at the National Institutes of Health in Bethesda, MD. The NIH Clinical Center is the world's largest hospital totally dedicated to investigational research and leads the global effort in training today's investigators and discovering tomorrow's cures. Learn more by visiting us online at http://clinicalcenter.nih.gov THIS SESSION BEGINS IN A WAY WHEN I WAS IN GRADUATE SCHOOL AND I WAS INTERESTED IN THE RELEVANCE OF INNATENESS FOR EPISTOMOLOGY, SOMETHING I'M SURE EVERYBODY'S BEEN THINKING ABOUT LATELY. [LAUGHTER] MY FIRST PUBLICATION WAS ARGUING THAT JOHN LOCKE ENCOURSED INNATENESS OF OUR CONCEPTS OF SECONDARY PROPERTIES. NOW, IS ANYBODY THINKING, THAT CHANGES EVERYTHING, RIGHT? SO PROBABLY DOESN'T CHANGE ANYTHING, AND SO FOR ME, ONE OF THE BIG ATTRACTIONS OF COMING HERE AND STAYING HERE IS TRYING TO DO RESEARCH ON ISSUES THAT ACTUALLY MATTER, AT LEAST TO SOME EXTENT, IN THE REAL WORLD AND TO ACTUAL PEOPLE, SO ONE OF THE FIRST REAL PAPERS I WROTE WAS ON DECEPTION IN CLINICAL RESEARCH AND TRYING TO PROPOSE WHAT I THOUGHT WAS THE RIGHT WAY TO HANDLE DECEPTION IN RESEARCH, A METHOD THAT MIGHT ALLOW SOME DECEPTION TO GO ON BUT IN A WAY THAT RESPECTED SUBJECTS, AND AFTER THAT PAPER GOT PUBLISHED, I GOT TWO PHONE CALLS FROM INVESTIGATORS WHO WERE INTERESTED IN TRYING TO IMPLEMENT MY APPROACH. THEY THOUGHT MAYBE IT WAS A GOOD IDEA AND THEY WANTED TO TRY TO IMPLEMENT IT. MY INITIAL REACTION, I WAS VERY EXCITED SOMEBODY ACTUALLY CARED ABOUT SOMETHING I HAD WRITTEN, AND THEN I WAS WALKING HOME FROM THE METRO THAT NIGHT AND I WAS THINKING, OH, CRAP, WHAT IF I'M WRONG? WHAT IF I SORT OF MESSED THIS WHOLE THING UP, THESE GUYS ARE GOING TO TAKE MY METHOD, THEY'RE GOING TO DO IT, IT'S GOING TO SCREW UP THE RYE SECH, PISS OFF THEIR SUBJECT AND IT'S GOING TO BE ALL MY FAULT. FOR A COUPLE DAYS THAT BOTHERED ME, NOT A WHOLE LOT, GIVEN WHAT I DO AND THE INFLUENCE VI ON PEOPLE. FOR ME, THAT BRINGS US TO THE TOPIC TODAY WHICH IS HOW WE RESPOND TO MEDICAL MISTAKES, AND I THINK THE PEOPLE WHO DO WHAT I DO ARE IMPRESSED BY CLINICIANS WHO DO WHAT THEY DO IF YOU'RE A HUMAN BEING, YOU'RE GOING TO MAKE A MISTAKE, IF YOU'RE LIKE ME, YOU MAKE A MISTAKE, YOU'RE PROBABLY NOT GOING TO HURLT SOMEBODY VERY MUCH. IF YOU'RE A CLINICIAN, THERE'S THE POTENTIAL THAT SOMEBODY COULD GET REALLY HURT, I THINK THAT MAKES WHAT CLINICIANS DO INCREDIBLY IMPRESSIVE IN THE FACT THAT PEOPLE CONTINUE TO DO IT. SO PEOPLE PROBABLY KNOW HISTORICALLY, THERE WAS THE THOUGHT THAT WE SHOULDN'T TALK ABOUT MISTAKES TOO MUCH, WE SHOULD TRY TO HIDE THEM, MAYBE IT'S GOING TO UNDERMINE TRUST IN CLINICIANS AND IN MEDICAL INSTITUTIONS, AND THAT'S CHANGED FAIRLY RADICALLY OVER THE LAST MAYBE 10 TO 20 YEARS, WHERE THERE'S MUCH MORE EMPHASIS ON THE IMPORTANCE OF BEING TRANSPARENT ABOUT MISTAKES, AND THAT LEADS TO A LOT OF QUESTIONS. THE QUESTION WE'RE GOING TO FOCUS ON TODAY IS THE QUESTION OF WHO SHOULD DISCLOSE MEDICAL MISTAKES AND WHO SHOULD APOLOGIZE FOR THEM. AS YOU'LL HEAR, THERE ARE AT LEAST FOUR DIFFERENT PROMINENT APPROACHES THAT PEOPLE ARE ENDORSING, SO WE'RE GOING TO TRY TO THINK THROUGH WITH OUR PRESENTER AND DISCUSSANT WHAT MIGHT BE THE BEST APPROACH. AS PEOPLE WHO COME HERE A LOT KNOW, WE TYPICALLY HAVE THE CLINICIAN PRESENT THE CASE. IN THIS CASE, WE'RE INTERESTED NOT ONLY IN THE ETHICAL ISSUES THAT ARE RAISED BY THIS CASE BUT WE'RE ALSO THINKING AT THE CLINICAL CENTER OF WHAT APPROACH WE WANT TO ADOPT IN DISCLOSING AND APOLOGIZING TO MEDICAL MISTAKES, SO INSTEAD OF THE INVOLVED CLINICIANS, WE'RE GO TO HAVE LAURA LEE PRESENT THE CASE. LAURA LEE, FOR A LOT OF PEOPLE AROUND HERE, KNOW HER AS THE DIRECTOR OF THE OFFICE OF PATIENT SAFETY IN CLINICAL QUALITY AT THE CLINICAL CENTER AND IS VERY INTERESTED IN THINKING THROUGH HOW WE SHOULD DISCLOSE AND APOLOGIZE FOR MEDICAL MISTAKES. SO THANKS FOR JOINING US, LAURA. [APPLAUSE] >> I THINK THIS MAY BE ONE OF THE PINNACLES OF MY CAREER HERE, I NEVER, EVER THOUGHT I'D BE GIVING ETHICAL GRAND ROUNDS. SO THANK YOU ALL. THOSE OF YOU THAT KNOW ME WILL UNDERSTAND THAT. I WOULD LIKE TO DISCLOSE THAT I HAVE NO CONFLICTS OF INTEREST FOR THIS PRESENTATION ABOUT DISCLOSURE. SO THE GOALS FOR MY PART OF THE PRESENTATION ARE TO DESCRIBE A CASE INVOLVING MEDICAL ERROR, TO PROPOSE FOUR POSSIBLE APPROACHES TO DISCLOSING AND APOLOGIZING FOR THOSE ERRORS, AND TO DISCUSS THE PROS AND CONS, ADVANTAGES, DISADVANTAGES OF THOSE APPROACHES. SO WE'RE GOING TO START WITH THE CASE. AB WAS A YOUNG ADULT WHO CAME HERE WITH MITOCHONDRIAL DYSFUNCTION AND WAS ENROLLED IN OUR UNDIAGNOSED DISEASES NETWORK PROTOCOL. THIS PROTOCOL, MANY OF YOU MAY KNOW, INVOLVES A ONE-WEEK INTENSIVE EVALUATION TO TRY TO UNDERSTAND AND IDENTIFY THE UNDERLYING CAUSES OF VERY RARE OR DIFFICULT TO DIAGNOSE DISORDERS. SO AS PART OF THIS EVALUATION, AB WAS SENT TO SURGERY TO HAVE A MUSCLE BIOPSY, SKIN BIOPSY AND LUMBAR PUNCTURE, ALL THREE PRETOURS WERE PROCEDURES WERE CLINICALLY INDICATED. NOW AS PART OF AB'S MEDICAL HISTORY, THERE WAS A, QUOTE, UNUSUAL RESPONSE TO PROAPFOL, WHICH IS AN ANESTHETIC AGENT. AS A RESULT, THE PERIOPERATIVE MEDICINE TEAM, THE ANESTHESIOLOGIST AND THE CARE TEAM DETERMINED THAT THEY'D USE ANOTHER ANESTHETIC AGENT, KETAMINE, FOR THE PROCEDURE INSTEAD OF THE PROPOFO WILL HAVE. ALL THREE PROCEDURES WERE PERFORMED SUCCESSFULLY, HOWEVER IMMEDIATELY FOLLOWING, AB REMAINED DEEPLY SEDATED FOR A VERY LONG PERIOD OF TIME, MUCH LONGER THAN ANYBODY ANTICIPATED. THE FAMILY BECAME VERY CONCERNED NOT ONLY FOR AB'S WELFARE, BUT ALSO WORRIED THAT THEIR ANESTHESIA OPTIONS MAY HAVE BEEN LIMITED BECAUSE IF THE PATIENT ALREADY HAD A, QUOTE, UNUSUAL RESPONSE TO PROPOFOL AND NOW WE HAD THE SENSITIVITY TO KETAMINE, MOVING FORWARD, AND THIS PATIENT WAS LIKELY TO NEED MORE SURGICAL PROCEDURES, THAT THEY'D HAVE VERY LIMITED ANESTHETIZING OPTIONS. SO AFTER SEVERAL HOURS, AB FINALLY BECAME ALERT, HAD NO LONG TERM SEQUELAE OR CONSEQUENCES FROM THE SEDATION, AND THE REMAINDER OF THE PATIENT STAY AT THE CLINICAL CENTER WAS UNEVENTFUL. LIKE EVERY ERROR OR LAPSE THAT OCCURS HERE THAT'S SIGNIFICANT, MY GROUP WORKS WITH THE TEAM THAT WAS INVOLVED EITHER TO DO A ROOT CAUSE ANALYSIS OR IN THIS CASE WE DID SORT OF A DEEP TIEF DEEF TO TRY TO UNDERSTAND WHY AN EVENT HAPPENS. WE'RE NOT INTERESTED IN BLAME, WE JUST WANT TO UNDERSTAND WHY IT HAPPENED AND HOW WE CAN KEEP IT FROM HAPPENING IN THE FUTURE. AFTER LOOKING AT THE CLINICAL DOCUMENTATION, IT WAS CLEAR THAT WHAT WAS THE ROOT CAUSE OF THIS EVENT WAS THAT THERE WAS A LAPSE AND INSTEAD WE KEPT THE INDUCTION DOSE OF KETAMINE GOING LONGER THAN IT SHOULD HAVE INSTEAD OF LOWERING IT TO A MAINTENANCE DOSE LATER IN THE PROCEDURE, THE PATIENT RECEIVED SORT OF A SUPER THERAPEUTIC DOSE OF KETAMINE DOOR MUCH LIAR THAT MOST LIKELY LED TO PROLONGED SEDATION AFTER THE SURGERY AND NOT THE SENSITIVITY TO THE KETAMINE, WHICH WAS GOOD NEWS TO THE FAMILY BECAUSE THEN THEY HAD SOME OTHER OPTIONS. SO THAT'S THE CASE, WE CLEARLY HAD AN ERROR LAPSE THAT OCCURRED SO THE NEXT PIECE OF THE PROCESS IS TALKING TO THE FAMILY AFTER WE DID THE INVESTIGATION, TALKING TO THE FAMILY ABOUT THAT THAT. SO WE ALL KNOW MEDICAL ERRORS IS A HUGE PROBLEM IN THE UNITED STATES, IF YOU TOOK THE CDC LEADING CAUSE OF DEATH IN THE UNITED STATES, DEATH ATTRIBUTED TO MEDICAL ERRORS NOW IS ABOUT THIRD ON THAT LIST AND SCORES MORE PATIENTS ARE HARMED EVERY YEAR. SO BEING TRANSPARENT IS IMPERATIVE AND CRITICAL HOWEVER, AS DAVID MENTIONED, WE STILL HAVE A LOT OF ANGST AS PRACTITIONERS AROUND DOING THAT. IN FACT, STUDIES HAVE DEMONSTRATED AS HE INDICATED THAT HISTORICALLY, PRACTITIONERS HAVE FELT AS THOUGH DISCLOSURE AND APOLOGY CERTAINLY SOMEHOW IMPLIES FAULT AND THAT CAN LEAD TO LITIGATION AND THAT CAN ERODE TRUST BETWEEN THE PRACTITIONERS AND THEIR PATIENTS. IF YOU LOOK AT WORK DONE BY GALLAGHER AND HIS ASSOCIATES FROM SEATTLE AND UNIVERSITY OF ILLINOIS CHICAGO AND NOW HERE LOCALLY WITH MEDSTAR, THE STUDIES REALLY DEMONSRATE THAT IT'S QUITE TO THE CONTRARY. BY BEING TRANSPARENT, OPEN AND DISCLOSING THESE ISSUES, THE IT ACTUALLY DECREASES THE LIKELIHOOD OF LITIGATION AND ACTUALLY WORKS TO RESTORE TRUST BETWEEN PATIENTS AND THEIR PRACTITIONERS. THE SAME GROUP OF FOLKS LOOKED AT WHAT PATIENTS WANTED TO KNOW AND LOOKED AT IT FROM A PATIENT'S PERSPECTIVE. QUITE SIMPLY, PATIENTS WANT TO KNOW WHAT HAPPENS TO THEM, THEY DESERVE TO KNOW WHAT HAPPENS TO THEM, AND THEY ACTUALLY REPORT THROUGH THESE STUDIES THAT DISCLOSURE ACTUALLY ENHANCES TRUST WITH THEIR PRACTITIONERS AND REALLY PROVIDES SOME REASSURANCE THAT THE EVENT WON'T HAPPEN AGAIN OR THAT IT'S MAYBE NOT AS BAD AS THEY HAD ENVISIONED. AND SO THIS IS WHAT PATIENTS ACTUALLY WANT US TO DO FOR THEM WHEN WE ACKNOWLEDGE -- WHEN WE IDENTIFY AN ERROR AND AN ERROR OCCURS. FIRST THEY WANT A GENUINE APOLOGY. EMPHASIS ON GENUINE. THEY WANT TO KNOW WHAT HAPPENED. THEY WANT AN EXPLANATION OF WHAT HAPPENED, AND SOMETIMES IF YOU'VE EVER BEEN INVOLVED IN AN ERROR DISCLOSURE, THEY WANT REALLY, REALLY, REALLY DETAILED EXPLANATION OF WHAT HAPPENED. THEY WANT AN ACCEPTANCE OF RESPONSIBILITY EITHER BY THE ORGANIZATION AND/OR THE INDIVIDUAL. THAT'S NOT MEANING BLAME. THEY WANT TO KNOW THAT AS THE CLINICAL CENTER, WE TAKE RESPONSIBILITY FOR WHAT HAPPENS TO YOU HERE. IT'S OUR RESPONSIBILITY TO UNDERSTAND WHY IT HAPPENED. AND THEN ONCE WE FIGURE OUT WHY IT HAPPENED, THEY WANT REASSURANCE THAT WE'RE ACTUALLY DOING SOMETHING ABOUT IT SO IT'S NOT GOING TO HAPPEN TO THEM AGAIN OR THEIR LOVED ONE OR THE NEXT PATIENT THAT'S LYING IN THAT SAME BED, IN THAT SAME VULNERABLE POSITION. SO THEY WANT AN APOLOGY, THEY WANT TO KNOW WHAT HAPPENED, THEY WANT TO KNOW THAT WE TAKE IT SERIOUSLY AND ARE TAKING RESPONSIBILITY FOR IT AND THAT WE'RE ACTUALLY DOING SOMETHING ABOUT IT SO IT DOESN'T HAPPEN AGAIN. SO THE QUESTION IS NOT SHOULD WE DISCLOSE AND APOLOGIZE, IT'S REALLY -- THE QUESTION SHOULD BE WHO SHOULD BE DISCLOSING AND APOLOGIZING AND WHAT SHOULD THAT PROCESS LOOK LIKE. TODAY WE'RE GOING TO OFFER YOU FOUR OPTIONS TO THINK ABOUT AND RE REBECCA IS GOING TO TALK ABOUT THOSE A LITTLE BIT. THE FOUR OPTIONS ARE THE PATIENT'S CAREGIVER OR CARE TEAM DOES IT, THE PERSON WHO WAS INVOLVED OR RESPONSIBLE FOR THE EVENT, ERROR, UNTOWARD EVENT DOES IT, TRAINED RESPONDER, OR AN ORGANIZATIONAL OFFICIAL OR REPRESENTATIVE. SO WE'LL GO THROUGH EACH OF THESE AND OUR VIEW OF THE PROS AND CONS, DISADVANTAGES AND VAPGS. SO LET'S ADVANTAGES. THE CAREGIVER, THE COULD BE THE P.I., THE ATTENDING, AND THAT PERSON DISCLOSES THE ERROR AND APOLOGIZES. INDEPENDENT OF THE PERSON WHO WAS INVOLVED. SO SOME OF THE ADVANTAGE, OBVIOUSLY WE HAVE AN EXISTING RELATIONSHIP WITH THAT PATIENT AND HOPEFULLY THERE'S SOME DEGREE OF TRUST BETWEEN THE CARE TEAM AND THE PATIENT. THAT PERSON KNOWS ABOUT THAT PATIENT, THEY UNDERSTAND WHAT'S GOING ON WITH THE PATIENT, AND THE PRACTITIONER IS RIGHT THERE AND AVAILABLE TO PROVIDE ANY ADDITIONAL TREATMENT OR FOLLOW-UP THAT NEEDS TO HAPPEN. NOW SOME OF THE DISADVANTAGES INCLUDE THAT PRACTITIONER LIKELY WAS NOT INVOLVED IN THE ERROR, SO THEY MAY NOT KNOW THE DETAILS, AND SOMETIMES THAT CAN BE FRUSTRATING TO THE PATIENT BECAUSE THEY WANT TO KNOW ALL THOSE DETAILS. THERE MAY BE A LACK OF EITHER COMFORT AND/OR SKILL IN HAVING THESE KINDS OF DIFFICULT CONDITIONS. I BET IF I ASKED FOR A RAISE OF HANDS, NOT A LOT OF PEOPLE HAVE HAD TRAINING ABOUT HOW TO HAVE THESE DIFFICULT DISCUSSIONS HERE AT THE CLINICAL CENTER, I THINK IT'S SOMETHING WE NEED TO THINK ABOUT, SO THAT DEFINITELY PLAYS INTO A DISADVANTAGE HERE. THE CAREGIVER MAY NOT KNOW WHAT'S GOING ON ORGANIZATIONALLY TO TRY TO REDUCE THE RUSK OF RISK OF THIS SAME TYPE OF EVENT FROM HAPPENING IN THE FUTURE. THESE TWO ARE INTERESTING CONCEPTS AND I THINK IMPORTANT, IF YOU TAKE AWAY THE PERSON MOST INVOLVED, YOU TAKE AWAY THE OPPORTUNITY FOR THAT PERSON TO OFFER A GENUINE APOLOGY TO THE PATIENT FOR HAVING BEEN INVOLVED IN THAT EVENT. AND LIKEWISE, IF THE PATIENT WOULD FEEL INCLINED TO FOR GIVE THAT CLINICIAN, THAT CLINICIAN DOESN'T HAVE THE OPPORTUNITY TO ACCEPT THAT FORGIVENESS. SO THOSE ARE TWO KEY CONCEPTS I THINK YOU'LL SEE AS WE GO THROUGH THOSE WILL CHANGE DEPENDING ON THE PERSON DELIVERING THIS INFORMATION. THE NEXT IS THE PERSON WHO WAS ACTIVELY INVOLVED AND/OR RESPONSIBLE FOR THE EVENT, AND THAT PERSON IS THE PERSON WHO SO ADVANTAGES, OBVIOUSLY THAT PERSON WAS THERE, HE OR SHE KNOWS WHAT HAPPENED AND IS ABLE TO GIVE THAT LEVEL OF GRANULARITY ABOUT THE EVENT THAT THE PATIENT MIGHT NEED AND REQUEST. AGAIN WE HAVE THE OPPORTUNITY TO GIVE THE PATIENT A GENUINE APOLOGY BECAUSE THAT PERSON WAS THERE INVOLVED IN THE EVENT AND LIKEWISE COULD ACCEPT THAT FORGIVENESS AND IS VERY IMPORTANT TO PRACTITIONERS WHO HAVE BEEN INVOLVED IN HARM OR ERRORS WITH PATIENTS. THEY'RE SOMETIMES CALLED THE SECOND VICTIM BECAUSE THEY SUFFER AS MUCH TRAUMA SOMETIMES AS THE PATIENT WHO IS INVOLVED, AND SO HAVING THAT ACT OF FORGIVENESS IS A VERY IMPORTANT PIECE OF CLOSURE FOR THOSE PRACTITIONERS. AND IT MAY WORK TO RESTORE TRUST IN THE PERSON WHO IS RESPONSIBLE. YOU HAVE THAT FACE TO FACE, AND IF THE PERSON IS VERY GENUINE IN THEIR APOLOGY, THEN THE PATIENT MIGHT HAVE MORE TRUST IN THAT PERSON MOVING FORWARD. NOW SOME OF THE DISADVANTAGES ARE THEY DON'T HAVE AN EXISTING RELATIONSHIP WITH A PATIENT, THEY MAY NOT HAVE THAT LEVEL OF TRUST. IT MAY LEAD TO SOME MISCOMMUNICATION, THERE MAY BE A LACK OF COMFORT AND SKILL IN ERROR DISCLOSURE. HAVING THOSE PEOPLE IN THE SAME ROOM AT THE SAME TIME MAY ACTUALLY LEAD TO CONFLICT OR EXACERBATE THE PROBLEM. AND YOU MAY MOVE FROM TRYING TO TALK ABOUT HOW WE CAN MAKE IMPROVEMENTS TO SLIPPING INTO SORT OF THE BLAME TERRITORY BY HAVING THOSE FOLKS IN THE SAME ROOM AT THE SAME TIME. AND AGAIN, THIS PERSON MAY NOT BE FAMILIAR WITH WHAT THE ORGANIZATION IS DOING TO TRY TO MITIGATE RISK MOVING FORWARD. SO NOW WE'VE MOVED FROM THE PRACTITIONER SIDE AND WE'RE NOW MOVING INTO FOLKS THAT MAY NOT BE CARE DELIVERY FOLKS. SO WE'RE CALLING THEM TRAWNED -- TRAINED RESPONDERS, ADVANCED TRAINING IN HOW TO TALK ABOUT THESE DIFFICULT ISSUES, TIS CLOSE ERRORS, OFFER APOLOGIES AND BE ABLE TO EXPLAIN WHAT THE ORGANIZATION IS DOING MOVING FORWARD, AGAIN, TO MITIGATE RISK IN THE FUTURE. SO ADVANTAGES ARE OBVIOUSLY THEY'RE PRACTICED AND SKILLED AT DO,ING THIS, PERHAPS MORE THAN THE BEDSIDE CAREGIVER IS. THEIR JOB IS TO PROMOTE AN UNDERSTANDING FOR THE PATIENT WHAT'S BEEN DONE IN THE ORGANIZATION TO TRY TO REDUCE RISK AS I SAID BEFORE. YOU TAKE AWAY THAT POTENTIAL FOR CONFLICT BETWEEN THE PERSON WHO WAS INVOLVED AND PERHAPS RESPONSIBLE BY HAVING THIS SORT OF THIRD PARTY INVOLVED, AND AGAIN, THEY WOULD BE MOST FAMILIAR WITH WHAT'S GOING ON ORGANIZATIONALLY. SOME OF THE DISADVANTAGES, THEY MAY NOT KNOW ALL THE DETAILS, THEY OBVIOUSLY DON'T HAVE A RELATIONSHIP WITH THE PATIENT. IT MAY SEND THE MESSAGE THAT WE'RE TRYING TO COVER UP FOR THE PERSON WHO IS RESPONSIBLE. WE'RE BRINGING SOMEBODY TOTALLY UNRELATED, NOW THEY'R GOING TO TRY TO DESCRIBE TO ME WHAT HAPPENED TO ME. WHERE IS THE PERSON WHO WAS INVOLVED? SO THAT MIGHT IMPLY SOME KIND OF COVERUP OR FAULT. IT REMOVES, AGAIN, THE OPPORTUNITY FOR APOLOGY AND FORGIVENESS, AND AGAIN, AS I SAID, WE DON'T HAVE THAT RELATIONSHIP WITH THE PATIENT. AND THEN THE FINAL OPTION IS AN INSTITUTIONAL REPRESENTATIVE OR LEADER IS A PERSON WHO GOES AND TALKS TO THE PATIENT, TELLS THEM ABOUT THE ERROR AND OFFERS THE APOLOGY. SO ONE OF THE KEY ADVANTAGES OF THIS IS THAT IT SENDS A MESSAGE THAT THE ORGANIZATION IS COMPLETELY ENGAGED IN THIS ISSUE, HAS TAKEN RESPONSIBILITY FOR IT, AND HAS SORT OF ROLLED UP THEIR SLEEVES HOPEFULLY AND IS DOING SOMETHING ABOUT IT. THAT LEADER CAN FACILITATE ANY ADDITIONAL TREATMENT THAT PERHAPS THE CLINICAL CENTER DOESN'T OFFER BUT THEY NEED TO HAVE IT DONE AT ANOTHER ORGANIZATION. MANY ORGANIZATIONS ARE ACTUALLY OFFERING COMPENSATION AT THE TIME OF AN ERROR AND THAT LEADER WOULD HAVE -- WE CAN'T DO THAT WITHIN OUR FEDERAL SYSTEM HERE, I DON'T THINK, BUT IN A PRIVATE -- IN THE PRIVATE SYSTEM, THAT LEADER HAS THE OPPORTUNITY AND THE OPTION TO THEN OFFER COMPENSATION IF THAT'S APPROPRIATE, AND AMENABLE TO THE FAMILY. AND THEN REALLY FOCUSING ON REDUCING FUTURE OCCURRENCES. AND THE DISADVANTAGES ARE SIMILAR TO THE ONES THAT WE'VE DISCUSSED IN THE PAST. THEY MAY NOT KNOW THE DETAILS OF THE CASE AGAIN, A LACK OF SKILL AND COMFORT IN ERROR DISCLOSURE, LIMITS THAT OPPORTUNITY FOR APOLOGY AND FORGIVENESS. IT MAY ALSO POTENTIALLY LOOK LIKE YOU'RE ROOT NIEZING APOLOGIES TO HAVE THIRD PARTIES COME AND THAT'S SORT OF THEIR JOB, TO GO DOWN AND TALK TO FAMILY AND APOLL JAIZ, AND AGAIN, THIS LACK OF RELATIONSHIP WITH THE PATIENTS. SO THOSE ARE THE FOUR OPTIONS WE'RE LAYING OUT IN FRONT OF YOU, AND I'M GOING TO HAND THE MICROPHONE OVER TO MY COLLEAGUES AND LET THEM TAKE YOU THROUGH WHICH ONE WE THINK IS THE MOST APPROPRIATE. >> THANKS, LAURA. SO JUST TWO NOTES ABOUT THIS CASE. ONE, AS PEOPLE HAVE HEARD IN THE PAST, OBVIOUSLY DOING THESE GRAND ROUND SESSIONS DEPENDS FOR US TO PRESENT THEIR CASES- AND WE RELY ON ALL THE CLINICIANS TO DO THIS. IN THIS KAI OBVIOUSLY ALLOWING US TO TALK ABOUT A MISTAKE THAT WAS MADE IS ESPECIALLY DIFFICULT, SO REAL THANKS TO EVERYBODY WHO IS INVOLVED IN THIS CASE FOR THE WILLINGNESS FOR US TO PRESENT IT. THE SECOND THING, AS IS ALWAYS THE CASE, THIS CASE I THINK IS INTERESTING, BUT THE POINT, THIS ISN'T A MORBIDITY AND MORTALITY CONFERENCE, THE POINT ISN'T TO GO OVER THIS CASE AND REHEARSE THE DETAILS OF THIS CASE. IT'S TO TRY TO USE IT AS THE IMPETUS FOR THINKING ABOUT WHAT'S THE BEST WAY TO, FOR OUR PURPOSES, DISCLOSE AND APOLOGIZE FOR MEDICAL MISTAKES, AND THE REASON WHY WE HAVE THESE FOUR, THESE ARE ALL FOUR THAT AT LEAST SOME INSTITUTIONS HAVE OR COMMENTATORS HAVE ENDORSED IN SOME INSTITUTIONS ARE USING AND THE QUESTION IS, WHICH ONE OR A COMBINATION OF THEM SEEMS LIKE THE BEST. SO TO HELP US WORK THROUGH THOSE QUESTIONS, WE HAVE AS A DISCUSSANT TODAY REBECCA DRESSER, WHO'S THE DANIEL NOYES KIRBY PROFESSOR OF LAW AND ALSO PROFESSOR OF ETHICS IN MEDICINE AT WASHINGTON UNIVERSITY IN ST. LOUIS. REBECCA IS ONE OF THE LEADING BIOETHICISTS IN THE COUNTRY, AND NORMALLY I SAY THAT, IT'S GREAT WE GET ONE OF THE LEADING PEOPLE, I ALWAYS THINK HAVING THE LEADING PEOPLE, WE'RE LUCKY WE CAN GET FABULOUS DISCUSSANTS HERE. FOR THE MOST PART, THAT'S GOOD. I NEVER SAW A DRAWBACK. TODAY WE SEE OUR FIRST POTENTIAL DRAWBACK, REBECCA IS IN DEMAND, PUTS DEMANDS ON HER VOICE, AND SHE'S HAVING A LITTLE BIT OF WE MAY DO A LITTLE BIT OF TAG TEAM HERE IF SHE NEEDS HELP WITH PRESENTING SOME OF HER COMMENTS, BUT REBECCA IS GOING TO AT LEAST START FOR US AND THANKS TO REBECCA FOR FIGHTING THROUGH THIS. WE'RE GOING TO ASK THAT THEY TURN UP HER MIC. [APPLAUSE] >> THANK YOU. I APOLOGIZE TO YOU FOR THIS SITUATION. BUT I'M GOING TO GO AS FAR AS I CAN GO AND THEY WILL TAKE OVER FOR ME IF I CAN'T MANAGE. SO I HAVE NO INTERESTS AND THESE ARE MY OBJECTIVES. I WON'T READ THEM. [LAUGHTER ?CHT] IT'S ALWAYS GREAT TO START WITH A DEFINITION, AND ESPECIALLY HERE, NOTICE THAT THE MISTAKE IS A DEVIATION FROM ACCEPTED STANDARS, WHETHER OR NOT IT ACTUALLY CAUSES HARM. NOW, MIGHT SAY, WELL, WHY DOES THAT MATTER IF THERE'S NO HARM DONE, WHY DO WE CARE? WELL, NO HARM DONE IS IF IT'S RISKY CONDUCT, IT'S POSSIBLE HARM DONE. SO THINK ABOUT SOMEBODY IS DRIVING 60 IN A 30-MILE PER HOUR ZONE, WE WANT THEM STOPPED AND DISCIPLINED AND DETERRED, EVEN IF THEY WERE LUCKY ENOUGH NOT TO HURT ANYONE, RIGHT? SO IN THE MEDICAL AREA, IF THERE IS A PRACTICE THAT IS RISKY OR A PERSON WHO'S RISKY, WE WANT TO KNOW THAT SO WE CAN ADDRESS AND TRY TO PREVENT FUTURE HARM. EVEN THOUGH THE FIRST INCIDENT, SOMEONE WAS LUCKY AND DIDN'T CAUSE ANY HARM. THE OTHER THING IS, EVEN IF CLINICIANS OR OTHERS SEE IT AS A MINOR HARM, THE MINOR HARM IS IN THE EYES OF THE BEHOLDER FOR THE PATIENT OR THE FAMILY. IT MIGHT BE A BIG HARM. THEY'RE DEALING WITH IT IN EVERYDAY LIFE, SO WE WANT TO TELL PEOPLE ABOUT THINGS THAT MATTER TO THEM, EVEN IF WE MIGHT THINK IT'S NOT SUCH A BIG DEAL. SO FOR EXAMPLE, HERE IF THE FAMILY HADN'T LEARNED ABOUT THE MISTAKE, THEY WOULD BE AFRAID IN THE FUTURE WHEN THE PATIENT NEEDS AN ANESTHETIC BECAUSE IS SENSITIVE TO THE AGENT. IF THERE'S NO -- IF THE HARM SEEMS ABSENT OR SMALL, THERE CAN BE TEMPTATION TO ENGAGE IN WHAT TOM GALLAGHER CALLS BE NEF LANT BENEVOLENT DECEPTION, WHERE WE'LL JUST DO MORE HARM AND THEY'LL BE MORE UPSET. BUT ONE PROBLEM THEY POINT OUT IS, IF YOU'RE LOOKING AT IT FROM YOUR PERSPECTIVE AS AN INSTITUTIONAL PERSON OR CLINICIAN, THEN YOU HAVE AN INHERENT CONFLICT OF INTEREST AND YOU'LL STILL BE BIASED IN EVALUATING MORE HARM THAN GOOD, YOU MIGHT DO THAT. SO THIS RECOMMENDS THAT UNLESS YOU HAVE A SYSTEM WHERE YOU ACTUALLY HAVE SOME MUTUAL PEOPLE BALANCING HARMS AND BENEFITS TO THE PATIENT OF DISCLOSURE, THEN YOU SHOULD NOT RELY ON THIS CONCEPT AS A BASIS FOR FAILURE TO DISCLOSE. NOW, SOMETIMES PEOPLE WHO ARE INVOLVED IN MISTAKES TRY TO HIDE IT FROM EVERYONE. MAYBE A COUPLE PEOPLE KNOW ABOUT IT AND THEY DON'T WANT ANYONE TO KNOW. AND FIRST OF ALL, HOW THEY EVER -- TALK ABOUT WHAT A TANGLED WEB WE WE'VE WHEN FIRST WE PRACTICE TO DECEIVE, AND PROBABLY CAN'T GET AWAY WITH IT. BUT ALSO WHEN WE'RE TAKING A SYSTEMS APPROACH TO ERROR REDUCTION, LIKE AN AILING INDUSTRY, YOU WANT TO KNOW ABOUT NEAR MISSES, SO AS I SAID EARLIER, IF IT'S RISKY, SOME THINGS CAN BE DONE IN THE SYSTEM. MAYBE FOR EXAMPLE HERE, MAYBE THERE'S A WAY TO CHECK UP ON THE ANESTHESIA ADMINISTRATION TO MAKE SURE THE INITIAL DOSE IS LOWERED AS APPROPRIATE, SO THERE MIGHT BE A MECHANISM TO PUT THAT IN PLACE, AND YOU WON'T KNOW ABOUT IF THE MISTAKE IS NOT DISCLOSED. SIMILAR, IF YOU HEAR ABOUT FIVE OR 10 SIMILAR INSTANCES, THEN YOU KNOW, WELL, WE NEED TO DO SOMETHING IN THE SYSTEM TO FIX IT. HOW AM I DOING? OH, THIS IS TERRIBLE. SO ALSO AS WAS MENTIONED, IN MISTAKES, WE DO HAVE ANOTHER VICTIM, AND CLINICIANS HAVE WRITTEN VERY COMPELLINGLY ABOUT HOW DIFFICULT IT IS FOR THEM TO KIEL DEAL WITH MISTAKES. THEY NEED HELP, THEY NEED -- OFTEN NEED SOME COUNSELING, THEY NEED TO TALK ABOUT IT, AND IF THEY DON'T, SOMETIMES THEY'LL SELF-MEDICATE, THEY'LL START DOING THINGS THAT ARE SELF DESTRUCTIVE OR HARMFUL TO PATIENTS. SO THIS IS THE REASON IT NEEDS TO COME OUT, EVEN THOUGH THEY MIGHT NOT THINK SO. AND THEN THE THIRD THING IS THERE ARE A SMALL NUMBER OF PEOPLE WHO ARE DANGEROUS TO PATIENTS, AND SO WE NEED TO KNOW WHEN THEY MAKE MISTAKES, MAYBE THEY'RE ABUSING ALCOHOL OR SOMETHING, THEY'RE HAVEING -- PROBLEMS, SO THEY NEED TO BE FOUND AND HELPED AND TAKEN OUT OF THE SYSTEM FOR A WHILE PROBABLY. NOW, SOME REASONS TO DISCLOSE TO PATIENTS. THESE ARE SOME MORE, THIS FIRST ONE IS A VERY WELL -- ANOTHER THING IS IF PEOPLE ARE ACTUALLY INJURED IT LOOKS LIKE THIS PATIENT WASN'T, BUT WHEN PEOPLE ARE, THEY NEED TO KNOW, OKAY, THERE IS A CONDITION THAT YOU'RE GOING TO NEED TO HAVE MONITORED OR TREATED, AND OBVIOUSLY THAT'S ESSENTIAL TO HEALTH. OF THE PATIENT. THIS WAS ALREADY MENTIONED, BUT THE THIRD ITEM, AARON LAZAAR IS A PHYSICIAN WHO SPENT A LOT OF TIME WRITING ABOUT MISTAKES, STUDYING THEM, AND HE SAYS THE PEOPLE AND THE FAMILY AND PATIENT, NEED TO HEAR FROM THE INVOLVED INDIVIDUALS REMORSE, SHAME, FORBEARANCE AND HUMILITY, AND SO THEY WANT TO SEE THAT THE PERSON WHO MADE I MISTAKES CARES ABOUT THE MISTAKES CARES ABOUT THEM. SO I THINK THAT'S REALLY RELEVANT TO THINKING ABOUT WHO SHOULD APOLOGIZE OR AT LEAST THE BE INVOLVED IN THE APOLOGY. AND THEN REPARATIONS, NOT ONLY IF THERE'S A FINANCIAL OFFER BUT SOMETHING ABOUT WHAT WE'RE GOING TO DO TO PROTECT FUTURE PATIENTS, PATIENTS AND FAMILIES REALLY WANT TO HEAR THAT. WHEN APOLOGIES ARE GOOD, ALL OF THESE THINGS HAPPEN, PATIENTS AND FAMILIES TALK ABOUT WHEN THERE'S A MISTAKE, THEY FEEL THAT SOMEONE DIDN'T CARE ABOUT THEM AS A PERSON. AND THEY TALK ABOUT FEELING THEIR DIGNITY HARMED, AND THAT MAY BE SURPRISING BUT IT'S LIKE, WELL, THESE PEOPLE AT ANY TIME EVEN PEOPLE DIDN'T EVEN CARE ENOUGH TO DO WHAT THEY TO HEAR SOMETHING ABOUT REMORSE AND WHY IT HAPPENED. AND HOW IT WILL BE PREVENTED. THEY WANT TO BE ABLE TO SAY WHAT THEY FEEL ABOUT IT AND THEY WANT AN OPPORTUNITY TO VENT. THIS CAN BE HARD TO HEAR, RIGHT? BUT IT'S WHAT THEY'RE OWED. IF PATIENTS ARE NOT TREATED RIGHT, THEY BEAR THE HEAVIEST BURDEN OF THE MISTAKES, AND WHY WHY SHOULD THEY, JUST AN INNOCENT VICTIM, HAVE THE HEAVIEST BURDENS OF AN ACTION THAT THEY REALLY DIDN'T HAVE ANYTHING TO DO WITH? THIS IS AN EXCELLENT ARTICLE. I RECOMMEND IT. I USED TO PUT TOGETHER MATERIALS FOR STUDENTS AT WASH-U FOR THIS SESSION ON ETHICS OF MISTAKES, AND I ALWAYS HAD THEM READ THIS ONE. HE'S VERY PASSIONATE, AND I THINK REALLY A GOOD WAY TO GET EDUCATED ABOUT THIS ISSUE. IS TO READ HIS PIECE. HE TALKS ABOUT FAILED APOLOGIES OFTEN BEING TOO VAGUE, THINGS LIKE, I APOLOGIZE FOR WHAT HAPPENED. WELL, WHAT HAPPENED? OR, MISTAKES WERE MADE. THOSE OF US WHO ARE OLD ENOUGH TO REMEMBER WATERGATE, THAT WAS A VERY COMMON APOLOGY THAT WE HEARD THEN. BY THE WAY, APOLOGIES ARE IMPORTANT IN ALL AREAS OF LIFE. WE'RE HEARING A LOT OF APOLOGIES THESE DAYS ABOUT CERTAIN OTHER KINDS OF MISCONDUCT. THERE WAS AN INTERESTING PIECE WHERE THEY TOOK THE APOLOGIES FROM SOME OF THE LEADING MEN WHO HAD BEEN ACCUSED OF SEXUAL MISCONDUCT, AND DISSECTED THEM, AND RATED THEM ON HOW -- THEY WERE. SO YOU MIGHT ENJOY READING THAT. BUT PEOPLE CAN TELL WHEN THEY'RE NOT SINCERE. IF YOU'RE JUST DOING THIS BECAUSE SOMEBODY IS TELLING YOU YOU HAVE TO, THEY CAN TELL. SO YOU HAVE TO BE GENUINE. THEN I JUST WANT TO CLOSE BY MENTIONING AN ARTICLE THAT WAS RECENTLY IN -- JUST IN OCTOBER IN JAMA INTERNAL MEDICINE, SO IT'S VERY TIMELY. THEY INTERVIEWED 30 FAMILY -- OR PATIENTS WHO WERE INVOLVED IN MISTAKES WHERE THERE WAS ACTUALLY SOME COMPENSATION GIVEN GIVEN. THEN 10 STAFF MEMBERS INVOLVED IN THAT PROCESS AND THREE DIFFERENT INSTITUTIONS. SO YOU SEE THAT IT WAS REALLY IMPORTANT FOR EVERYBODY, EVEN THE STAFF SAID THIS TOO, TO HAVE THE RIGHT PEOPLE PRESENT IN THE EARLY DISCLOSURE CONVERSATIONS, INCLUDING THE INVOLVED CLINICIAN. SO THIS WAS A SMALL SAMPLE, 40 INTERVIEWS, BUT THEY MENTIONED TO THEIR KNOWLEDGE IT'S THE FIRST ONE, I HOPE THEY DO MORE, BUT THE VAST MAJORITY SAID YOU NEED TO HAVE THE INVOLVED CLINICIAN THERE. IF THEY HEARD THE PERSON INVOLVED IS NOT GOOD AT THESE KINDS OF CONVERSATIONS OR IS TOO UPSET, THEY WERE NOT SYMPATHETIC. SO THE AUTHORS SAID IN THAT SITUATION, WHAT YOU NEED IS TO TRAIN AND COACH THE PEOPLE TO HELP THEM WITH THIS DIFFICULT CONVERSATION. SO IT WAS MENTIONED THAT PEOPLE HAVE ADVANCED TRAINING IN DISCLOSURE. I THINK THERE, PROBABLY THE REALLY VALUABLE INVOLVEMENT IS TO WORK WITH THE INVOLVED CLINICIANS TO DEVELOP A GOOD DISCLOSURE RATHER THAN SUBSTITUTE FOR THE INVOLVED CLINICIAN. THAT WOULD BE MY VIEW, BUT WE CAN DEBATE THAT. AND ALSO THEY SAID WHEN CLINICIANS ARE NERVOUS ABOUT THIS, REMIND THEM THAT THE MOST IMPORTANT THING FOR THEM TO DO IS LISTEN. ANYONE CAN DO THAT. -- WE CAN'T LISTEN. PHYSICAL PRIVACY WAS IMPORTANT TO MANY PEOPLE. SOMEBODY TALKED ABOUT HEARING ABOUT THIS IN A ROOM WHERE THERE WERE OTHER PATIENTS. AND STUFF WAS GOING ON. AND THEY FELT THAT WAS VERY DISRESPECTFUL. SURPRISINGLY -- WELL, THIS IS NOT SURPRISING. THEY WANTED PEOPLE, RISK MANAGEMENT AND THOSE KINDS OF PEOPLE, TO BE INVOLVED IN THE DISCUSSION BUT THEY WANTED THAT LATER. THEY THOUGHT THAT WOULD BE BEST. WHEN THE RISK MANAGEMENT PEOPLE COME IN FIRST, OR ANOTHER INSTITUTIONAL OFFICIAL, SOME PEOPLE SAID THEY WONDERED IF THE PEOPLE WERE REALLY THERE TO HELP THE PATIENT OR JUST LIMIT THEIR LIABILITY. SO THEY WERE KIND OF SUSPICIOUS. JUST A FEW OTHER RECOMMENDATIONS. AS I MENTIONED, PEOPLE WANT TO BE HEARD. THESE VICTIMS. AND THEY DON'T WANT TO JUST GET INFORMATION, THEY WANT CLINICIANS AND STAFF TO LISTEN ATTENTATIVELY WITHOUT TAKING NOTES OR INTERRUPTING. AND THEY DON'T WANT PEOPLE TO SAY, OH, WELL, YOU'RE GETTING OFF THE TOPIC. THAT WAS MENTIONED. AS I SAID, THEY WANT TO VENT. AND THEN THIS IS WHAT -- I'VE SEEN THIS, THEY WANT TO HAVE AN ATTORNEY OR A PATIENT ADVOCATE PRESENT. NOW IT WASN'T SO CLEAR WHETHER THEY WANTED THAT IN THE FIRST OR THE SECOND CONVERSATION WITH RISK MANAGEMENT. BUT THEY FELT, YOU KNOW, VULNERABLE, AND THEY WERE WORRIED THAT IF THEY WERE OFFERED SOME COMPENSATION THAT THEY MIGHT BE TAKEN ADVANTAGE OF, SO THEY WANTED SOMEBODY THERE WITH THEM. IT WAS SURPRISING THAT A MAJORITY OF THE STAFF MEMBERS ALSO SUPPORTED THAT. YOU MIGHT THINK, WELL, WHY? THEY FOUND HAVING AN ATTORNEY OR ADVOCATE THERE WAS VERY REASSURING TO THE PATIENT AND FAMILY, AND SOMETIMES ACTUALLY ATTORNEYS COULD HELP PATIENTS FEEL BETTER IF THEY GET AN OFFER AND THE PATIENT AND THEIR FAMILY SAYS, O I WANT MORE THAN THAT, AND THE ATTORNEY SAYS THIS WAS AN EXAMPLE, IN ONE CASE THE ATTORNEY SAID, NO, THAT'S FAIR, THAT'S REASONABLE FOR WHAT HAPPENED TO YOU. AND SO EVERYBODY SETTLED DOWN. SO IN FACT, THE ATTORNEY CAN ACTUALLY PRESENT A BALANCED PERSPECTIVE, ALTHOUGH I'VE NEVER BEEN A REAL LAW I HAVE TO LAUER, I HAVE LA WYER, I KNOW THEY'RE NOT YOUR FAVORITE PEOPLE BUT SOME PEOPLE CAN DO WELL IN THIS SITUATION FOR BOTH SIDES. AND THEN THE FINAL THING IS, PATIENTS AND FAMILIES REALLY WANT TO KNOW WHAT THE INSTITUTION WILL DO TO PREVENT THIS FROM HAPPENING IN THE FUTURE. SO SOMETIMES MAYBE YOU HAVEN'T FIGURED THINGS OUT WELL ENOUGH TO KNOW IF THIS IS A ONE-SHOT THING OR THERE IS SOMETHING THAT NEEDS TO BE DONE MORE BROADLY. AND THE ADVICE THERE IS FOLLOW-UP. SEVERAL OF THE INTERVIEWED PATIENTS AND FAMILIES MENTIONED THEY WERE REALLY MAD WHEN THEY WERE TOLD, OKAY, YOU'RE GOING TO HEAR FROM US ABOUT WHAT OUR PLAN IS TO PREVENT THIS IN THE FUTURE, AND THEY NEVER DID. SO THIS FOLLOW-UP IS ESSENTIAL. ALL RIGHT. SO MY INITIAL RECOMMENDATION WOULD BE TO HAVE THE ANESTHESIOLOGIST INVOLVED IN THE INITIAL DISCUSSION, PERHAPS WITH SOME OF THE PRIMARY CAREGIVERS WHO KNOW THE PATIENT'S FAMILY AND THE FAMILY AND PATIENT KNOW THEM, SO THAT MIGHT BE A GREAT IMI NAUSEOUS AND, YOU KNOW, WITH PRIOR COACHING IF THAT'S NEEDED AND THEN A FOLLOW-UP WITH AN INSTITUTIONAL REPRESENTATIVE. SO THANK YOU SO MUCH FOR PUTTING UP WITH ME. AND I REALLY ENJOYED IT. THANK YOU. [APPLAUSE] >> ALL RIGHT. DO PEOPLE HAVE QUESTIONS FOR REBECCA OR LAURA, AND ALSO I'LL POINT OUT IN THIS CASE, LAURA'S OFFICE IS VERY INTERESTED IN INTERESTED AN D THE CLINICAL CENTER IS VERY INTERESTED IN COMING UP WITH AN APPROACH TO DISCLOSURE AND APOLOGY FOR MEDICAL ERROR, SO SUGGESTIONS/RECOMMENDATIONS ARE DEFINITELY WELCOME AS WELL. >> HOW MUCH DOES THE PRE-EVENT RELATIONSHIP BETWEEN THE PROVIDER AND THE PATIENT AND FAMILY PLAY IN TO THE DECISION? AGAIN, IF THIS IS A PROVIDE THAT'S WELL-KNOWN, HAS BEEN TAKING CARE OF THE PATIENT, IS WELL REGARDED BY THE PATIENT AND FAMILY, I COULD SEE THE DECISION BEING MADE ONE WAY, IF THIS IS SOMEBODY WHO'S REALLY NOT WELL-KNOWN TO THE PATIENT AND FAMILY OR MAY BE KNOWN FOR JUST A VERY SHORT PERIOD OF TIME THAT THEY DON'T HAVE AN ONGOING RELATIONSHIP WITH, HOW MUCH OF THAT -- HOW MUCH DO YOU THINK THAT SHOULD PLAY INTO THIS DECISION? >> SO THANK YOU FOR THE QUESTION. MONO PRESSURE HERE. SO I THINK THAT JUST INTUITIVELY, HAVING A GOOD RELATIONSHIP HELPS. I THINK THAT -- AND IT'S ONE THING THAT WE LOOK FOR WHEN WE'RE WORKING WITH FOLKS THAT NEED TO DISCLOSE, IS HOW THAT RELATIONSHIP IS, AND SO IN THIS EXAMPLE -- NOT IN THIS EXAMPLE BUT IN A SIMILAR EXAMPLE THAT HAPPENED WITH THE SAME SORT OF GROUP LATER ON, WE HAD THEM BOTH GO TOGETHER KNOWING THEY HAD A REALLY GOOD RELATIONSHIP WITH THE CARE TEAM. OUR COLLEAGUES AT THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY HAVE BEEN WORKING WITH FOLKS AT MEDSTAR, TIM MCDONALD AND KELLY SMITH THERE AND HAVE RECENTLY PUBLISHED IN THE LAST YEAR A PROGRAM CALLED "CANDOR," IT'S COMPENSATION AND RESOLUTION. BUT THEY REALLY ADVOCATE HAVING THIS TRAINED RESPONDER RESPOND FOR THAT VERY REASON, BECAUSE IT DOES TAKE THAT RELATIONSHIP OR LACK OF RELATIONSHIP SORT OF OUT OF THE MIX. SO I MEAN, IT'S NOT MUCH OF A DEFINITIVE ANSWER, BUT I THINK BEING REALLY ENGAGED WITH THE FOLKS THAT DO THIS FOR A LIVING OR KNOW A FAIR AMOUNT ABOUT IT, WORKING WITH YOUR INSTITUTE LEADERSHIP OR YOUR BRANCH LEADERSHIP AND REALLY SORT OF SORTING THROUGH WHO'S THE BEST PERSON BECAUSE JUST FROM EXPERIENCE, IF YOU START OFF ON THE WRONG FOOT, IT IS SO HARD TO GET BACK ON THE RIGHT FOOT WITH PATIENTS THAT HAVE BEEN AT THE POINTY END OF AN ERROR. IT'S REALLY DIFFICULT, AND THEN IT GETS MORE AND MORE DIFFICULT FOR THE CARE TEAM AND THE PERSON THAT'S INVOLVED TO GAIN CONFIDENCE TO GO BACK INTO THAT ROOM. SO IT A REALLY GOOD POINT. >> THAT REMINDS ME IN THE INTERVIEW STUDY, THEY MENTIONED THE PATIENT AND FAMILIES MENTIONED THAT THE FIRST CONTACT IS SO IMPORTANT, AND STAFF MENTIONED THIS TOO, IT GOES OFF THE RAILS IF THAT INITIAL CONTACT IS NOT SEAR RI. I WONDER, WHAT DO YOU THINK OF THE IDEA OF HAVEING THE RESPONSIBLE CLINICIAN TOGETHER WITH A TRUSTED CAREGIVER OR SOMEONE WHO'S FAMILIAR WITH THE PATIENT AND FAMILY? HAVE YOU TRIED THAT? DOES THAT WORK OR -- >> SO IT DOES WORK. I MEAN, THAT'S SORT OF MY PREFERRED WAY TO DO IT JUST FROM EXPERIENCE, MY COLLEAGUES AT AHRC WILL PROBABLY KILL ME FOR SAYING THAT PUBLICLY BUT ESPECIALLY IN THIS ENVIRONMENT, WE HAVE VERY STRONG RELATIONSHIPS WITH OUR PATIENTS, MUCH MORE THAN I THINK IN MAYBE A TYPICAL HEALTHCARE SYSTEM, SO I THINK HAVING THAT TRUSTED -- NOT -- AS I SAID, NOT IN THIS EXAMPLE BUT A SIMILAR EXAMPLE, AND AGAIN, IT INVOLVED NHGRI AND ANESTHESIA, AND THEY WENT TOGETHER. SO IT WAS THE ATTENDING PHYSICIAN, WHO HAS HAD A RELATIONSHIP WITH THIS FAMILY, AND ANESTHESIOLOGISTS WHO DIDN'T HAVE A RELATIONSHIP AN MAYBE NOT AS MUCH SKILL DEALING WITH TALKING ABOUT THESE THINGS WENT TOGETHER, AND IT WORKED VERY WELL WITH THAT FAMILY, BECAUSE THEY FELT COMFORTABLE BUT THEY ALSO HEARD FROM THE PERSON WHO WAS INVOLVED AND THAT PERSON WAS ABLE TO VERY CLEARLY EXPLAIN WHY IT HAPPENED, IT WASN'T FOR LACK OF WANTING THE RIGHT THING TO HAPPEN, IT WAS REALLY SYSTEMS ISSUES AND THINGS LIKE THAT. SO IN THIS ENVIRONMENT, I FEEL AS THOUGH THAT'S PROBABLY THE RIGHT APPROACH. >> I WAS GOING TO EMPHASIZE THAT, REBECCA MENTIONED AARON LAZARE, WHO'S WRITTEN A LOT ON THIS, AND HE ALSO HAS A VERY NICE BOOK FOR PEOPLE INTERESTED CALLED "UNAPOLOGY," AND ONE OF THE THINGS HE EMPHASIZES IS THAT THE NATURE OF THE RELATIONSHIP BETWEEN THE PERSON WHO'S HARMED AND THE PERSON WHO'S RESPONSIBLE ISN'T JUST RELEVANT TO WHO SHOULD DISCLOSE AND APOLOGIZE, BUT IT'S ALSO EXTREMELY FOREIGN THE MEANING AND SIGNIFICANCE OF THE MISTAKE ITSELF. WHEN IT'S A MISTAKE MADE BY SOMEBODY WHO YOU HAVE A LONG TERM RELATIONSHIP WITH, SOMEBODY WHO'S CARING FOR YOU OVER YEARS, IT'S NOT JUST A MATTER OF THIS HARM, BUT IT STARTS RAISING CONCERNS ABOUT THE RELATIONSHIP AND WHETHER OR NOT YOU CONTINUE WITH THIS PERSON, TRUST THAT PERSON, GET CAROL FROM THAT CARE FROM THAT PERSON THE NEXT YEAR. AS WE KNOW HERE, WE HAVE PATIENTS COME BACK FOR 10, 15, 20 YEARS, SO THAT ONGOING RELATIONSHIP COULD JUST BE CRITICAL TO THE WHOLE THING. ANYTHING ELSE, REBECCA? >> I WAS GOING TO SAY, I HEAR AT SOME POINT THERE WILL BE SOME COMPARATIVE TRIALS OF THE DIFFERENT METHODS. I MEAN, THAT WOULD BE GOOD, RIGHT? WHAT WAS THAT -- >> CAN CANDOR. >> VERSUS -- I THINK HARVARD HAS AN APPROACH SIMILAR TO WHAT WE HAVE BEEN STRESSING. IT MIGHT BE HARD TO DO, YOU KNOW, A COMPARISON, BUT YOU KNOW, AND THEN ASK PATIENTS AND FAMILIES HOW THEY FEEL ABOUT THE TWO DIFFERENT METHODS. >> THE NEXT SESSION IS GOING TO BE ON THE ETHICS OF A RANDOMIZED TRIAL. >> I'D LIKE TO GO ON RECORD AS SAYING I'D LIKE TO HAVE LESS ERRORS SO I HOPE -- I WANT NO ACCRUAL. >> HI. THANK YOU FOR THE INTERESTING DISCUSSION. I HAD A QUESTION ABOUT OPTION 1, HAVING THE PRIMARY CAREGIVER APOLOGIZE. SO I'M ASSUMING THAT THE PRIMARY CAREGIVER WAS NOT INVOLVD IN THE MI STALK THAT MISTAKE THAT WAS MADE IE . ALSO ASSUMING APOLOGIZING IS ADMITTING SOME DEGREE OF RESPONSIBILITY OR SOME DEGREE OF RESPONSIBILITY FOR THE MISTAKE THAT WAS MADE SO MY QUESTION, OR MAYBE IT'S A SUGGESTION, IS, IS THAT REALLY AN APOLOGY WHEN IT'S COMING FROM THE PRIMARY CAREGIVER IF THEY'RE UNRELATED TO THE MISTAKE THAT WAS MADE? IT SEEMS TO ME THAT IS A CASE OF I'M SORRY THAT THIS HAPPENED. SO IT DOESN'T REALLY MAKE SENSE TO ME THAT OPTION 1 IS LISTED WITH THOSE OTHER THREE, BECAUSE I ASSUME -- OR I UNDERSTAND WHY AN INSTITUTION CAN TAKE RESPONSIBILITY OR THE CLINICIAN WHO CAUSED THE MISTAKE CAN TAKE RESPONSIBILITY, I DON'T UNDERSTAND WHY THE PRIMARY CAREGIVER COULD TAKE RESPONSIBILITY IN THE FORM OF AN APOLOGY. >> SO I JUST WANT TO REMIND EVERYBODY THAT PROBABLY 99.9% OF THE TIME WHEN WE HAVE ERRORS, IT HAS NOTHING TO DO WITH AN INDIVIDUAL. IT HAS TO DO WITH THE SYSTEM AROUND THE INDIVIDUAL. SO TO SAY THERE'S ONE INDIVIDUAL THAT'S RESPONSIBLE IS REALLY HARD. I MEAN, THERE'S SOME TIMES IT'S TRUE, BUT -- SO I AGREE WITH YOU, THEY COULDN'T GIVE THE GENUINE APOLOGY, BUT OFTEN IT'S AWFULLY DIFFICULT TO PINPOINT, OKAY, WHO IS THAT PERSON THAT SHOULD BE APOLOGIZING IF, IN FACT, AN APOLOGY IMPLIES SOME SORT OF FAULT OR GUILT OR SOMETHING LIKE THAT. SO I MEAN, I JUST WANT TO PUT -- SORT OF SAY THAT AND KEEP THAT IN PEOPLE'S FOREBRAIN, IS THAT IT'S REALLY HARD TO LAY BLAME ON THESE THINGS BECAUSE MORE OFTEN OR NOT, THEY'RE SYSTEMS ISSUES. >> AND IN PHILOSOPHY WE SPEND SO MUCH TIME TALKING ABOUT CAUSATION, ALL THE DIFFERENT FACTORS THAT CAN GO INTO AN EVENT. SO I THINK THAT'S A REALLY GOOD POINT. I DO AGREE IT'S HARD FOR SOMEBODY WHO WASN'T EVEN INVOLVED IN THE MISTAKE TO APOLOGIZE, AND THAT REMINDS ME THAT MISTAKES ARE A SUBSET OF ADVERSE EVENTS. SO ADVERSE EVENTS HAPPEN WHEN THERE'S NO MISTAKE. WHENEVER YOU'RE DOING A PROCEDURE OR GIVING A MEDICATION, THERE ARE RISKS, SO SOMEBODY EXPERIENCES A RISK AND THAT'S AN ADVERSE EVENT, BUT IT'S NOT A MISTAKE BECAUSE BASED ON CURRENT KNOWLEDGE, THAT'S THE BEST WE CAN DO. SO LAZARE TALKS ABOUT WHEN THERE IS AN ADVERSE EVENT, BUT NOBODY WAS AT FAULT, CLINICIANS AND PEOPLE SHOULD SAY I'M SORRY FOR WHAT HAPPENED TO THE PATIENT, YOU KNOW, I'M SORRY HE OR SHE WAS IN THAT 2% WHERE THIS, YOU KNOW, HAPPENED, BUT, YOU KNOW, YOU DON'T APOLOGIZE FOR THAT. THAT'S A NATURAL HARM. SO I THINK EVEN WITH THE MISTAKE, THE RESPONSIBLE CLINICIAN CAN SAY YOU KNOW, I WORK HERE AND I FELT TERRIBLE THAT THIS HAPPENED TO YOU HERE, SOMETHING LIKE THAT. BUT THAT DOESN'T TAKE ON THE FAULT/RESPONSIBILITY EL EM. >> THANK YOU. GOOD RESPONSE. >> HELLO. THANKS FORT PRESENTATION. VERY INTERESTING. THANKS, REBECCA, FOR BEING A TROOPER THROUGH THIS. >> I PAID HIM. [LAUGHTER] >> THIS IS ALL VERY NEW TO ME. I HAVEN'T WRITTEN MUCH ABOUT MISTAKES, I'VE WRITTEN MANY MISTAKES. SO FIRST I HAVE A SUGGESTION FOR YOU AND THEN MAYBE A QUESTION. SO MY SUGGESTION IS, UNLESS YOU'VE ALREADY SEEN THIS, IT MIGHT BE HELPFUL TO INVESTIGATE WHAT THE POLICE AND MILITARY DO WHEN THEY HAVE TO APOLOGIZE FOR MISTAKES, IF AT ALL. I'M NOT REALLY SURE WHAT THE PROTOCOL IS THERE. AND MY QUESTION IS, DO YOU THINK SOMETIMES THE CAREGIVERS, THE HOSPITAL OR INSTITUTION, SHOULD -- OR IS OBLIGATED TO BACK UP THEIR APOLOGY WITH, SAY, FINANCIAL SUPPORT? YOU KNOW, IF SOMEONE BECOMES A QUADRIPLEGIC OR SOMETHING, THE HOSPITAL OR INSTITUTION SHOULD PROVIDE AID OR CARE FOR THIS FOR THE REST OF THEIR LIFETIME, OR MAYBE FOR SOME IMMEDIATE INTERVAL OF TIME AFTERWARDS. THANK YOU. >> WELL, THERE'S A HUGE MOVEMENT, THE DISCLOSURE, APOLOGY AND OFFER, DAO APPROACH. A LOT OF INSTITUTIONS, WHEN HARM HAPPENS AND IT'S RECOGNIZED IT'S THE RESPONSIBILITY OF THE ORGANIZATION, THEY WILL HAVE THE AUTHORITY TO AUTOMATICALLY OFFER. SO YEAH, COMPENSATION IS BECOMING A HUGE PIECE OF ERROR DISCLOSURE IN ORGANIZATIONAL RESPONSE TO THAT. AS YOU SAID, AS YOU MENTIONED THE ATTORNEYS BEING PRESENT JUST TO MAKE SURE THAT THEY SORT OF GET APPROPRIATELY COMPENSATED. BUT IT'S BECOMING MORE AND MORE AND MORE USUAL TO HAVE THAT HAPPEN. I THINK THE CURRENT FEDERAL SYSTEM MAKES THAT DIFFICULT, BUT I'M NOT GOING TO SPEAK FOR OUR LAWYERS. IF ANY OF OUR LAWYERS ARE IN THE AUDIENCE, I'D LOVE TO HEAR YOUR RESPONSE TO THAT. IT'S ALSO A GOOD POINT ABOUT LOOKING TO OTHER INDUSTRY. >> THANKS. >> THE INSTITUTE OF MEDICINE, YOU PROBABLY ARE FAMILIAR, THEY HAVE DONE SOME REPORT ON MISTAKES IN MEDICINE, AND THEY LOOKED AT OTHER CONTEXTS, AND I DON'T KNOW IF THEY LOOKED AT MILITARY/POLICE, BUT THE AIRLINE INDUSTRY IS ONE THAT THEY OFTEN CITE AS BEING SO GOOD AT REPORTING NEAR MISSES, ANY TIME ANYTHING IS OFF A LITTLE BIT, YOU KNOW, THEY HAVE THEIR COPILOT THERE, SO APPARENTLY THERE'S AN ETHICS OF, YOU KNOW, NOT TRYING TO COVER UP ANYTHING, AND YOU KNOW, AIRLINES HAVE BECOME AMAZINGLY SAFER THAN WHEN I WAS A KID, THERE WERE A LOT MORE CRASHES, AND IT'S PROBABLY PARTLY BECAUSE OF THIS APPROACH THAT THEY'RE TRYING TO DWELL A LOT ON THAT. AND YOU KNOW, THE PROBLEM WITH MALPRACTICE IS THAT SOMETIMES PEOPLE HAVE FELT THEY NEED -- THEY DESERVE AND THEY NEED COMPENSATION, THEY'RE SEVERELY INJURED, AND NOBODY OFFERS THEM ANYTHING. SO IT TAKES TIME AND THEY END UP PAYING A LOT OF LAWYERS, SOMEBODY DOES, AND SO THIS DEVELOPMENT, I THINK IS REALLY GREAT FOR PATIENTS AND INSTITUTIONS IN THAT YOU'RE TRYING TO BYPASS ALL THAT AND COME UP WITH A KIND OF A WORKER'S COMPENSATION IDEA THAT IS BASED ON ADDRESSING FINANCIALLY THE HARM THAT WAS DONE. INCLUDING THINGS LIKE TIME OFF OF WORK AND THAT SORT OF THING. SO I THINK THAT'S A GREAT DEVELOPMENT. >> IF YOU LOOK AT THE SYSTEMS AND ESPECIALLY IN SCANDINAVIAN COUNTRIES, THEY HAVE A TOTALLY DIFFERENT SORT OF MEDICAL/LEGAL COMPENSATION THAT IS NOT AT ALL BASED ON THE TORT CLAIM -- THE TORT SYSTEM HERE IN THE UNITED STATES, AND IT'S MUCH -- IT'S QUICKER, IT SEEMS MUCH MORE SENSIBLE AND -- YEAH. >> OKAY. I THINK THIS IS A WONDERFUL DISCUSSION OF MEDICAL MISTAKES AND ESPECIALLY SERIOUS ONES. THE QUESTION IS, WHAT IS THE THRESHOLD THAT YOU START GETTING INTO? FOR INSTANCE, WE ORDER A LAB TEST. THE PATIENT GETS STUCK FOR THE TEST, LITERALLY, THEY DRAW THE BLOOD AND THEY DIDN'T DO THAT PARTICULAR ONE, OR WE DIDN'T ORDER THE CORRECT ONES, AND WE HAVE TO SAY, SORRY, WE NEED TO GET TO YOU GO DOWN AND GET STUCK A SECOND TIME. SO THAT'S A MISTAKE, SOMEWHERE ALONG THE SYSTEM, BUT I DON'T THINK WE NEED TO GO INTO THIS WHOLE SYSTEM OF APOLOGIZING, GOING ON AND ON. YOU TELL THE PATIENT -- THEY EITHER SAY OKAY, I'LL DO IT AND I DON'T AND THAT'S THE END OF IT, USUALLY. >> YEAH, YOU DISCLOSED. >> THE COMMENT, DISCLOSURE IS IMPORTANT AND THEN THE QUESTION IS WHAT'S THE THRESHOLD. >> WHAT DO YOU DO AFTER THAT? WHAT HAPPENS AFTER THAT? IS THAT THE END OF IT OR DO WE GO ON TO THESE HIGHER LEVELS THAT WE'RE DISCUSSING? >> I THINK THAT'S A GOOD EXAMPLE OF THE URBAN EU OF ISSUE OF WHOSE PERSPECTIVE. SO IF YOU'RE A PATIENT SITTING THERE FOUR HOURS AND THEN FINDS OUT, OH, THEY HAVE TO DO THIS OVER AGAIN, I THINK THERE IS -- I MEAN, IT'S OBVIOUSLY NOT A MAJOR APOLOGY AND YOU DON'T NEED TO OFFER A FINANCIAL SETTLEMENT, BUT I THINK AN ACKNOWLEDGMENT THAT, YOU KNOW, YOU'VE SPENT A LOT OF TIME HERE, AND NOW, YOU KNOW, AND YOU'RE PROBABLY EXHAUSTED AND, YOU KNOW, WE'RE GOING TO HAVE TO PUT YOU THROUGH MORE WAITING AND STUFF. IF I WERE THE PATIENT, I WANT SOMETHING, AN ACKNOWLEDGMENT OF WE'RE SORRY THAT THIS HAPPENED TO YOU. WHEN I TAUGHT THIS AT WASH-U, WE USED A CASE THAT A PEDIATRICIAN DEVELOPED BASED ON HER EXPERIENCE, AND IT INVOLVED A FAMILY WHERE THEY BROUGHT THEIR YOUNG DAUGHTER TO THE E.R. WITH SOME KIND OF DIARRHEAL ILLNESS, AND SHE WAS TESTED AND, YOU KNOW, THERE WAS A TREATMENT, BUT NOBODY EVER GOT BACK TO THE FAMILY WITH THE RECOMMENDATION. SO THREE WEEKS LATER, THE PARENTS COME IN WITH THIS LITTLE GIRL WHO'S HAD DIARRHEA FOR THREE WEEKS, THE PARENTS HAVE BEEN TAKING CARE AND STAYING HOME WITH HER,SHE CAN'T GOTO DAYCARE, THEY'VE HAD TO CHANGE HER BED SHEETS THREE OR FOUR TIMES A DAY, IT HAD BEEN A NIGHTMARE. IF YOU'RE PARENTS, YOU CAN IMAGINE. SO I THINK -- AND THE PEDIATRICIAN, YOU KNOW, GAVE THEM TREATMENT AND THE FAMILY THOUGHT SHE WAS A MIRACLE WORKER BECAUSE THEY DIDN'T KNOW ABOUT THE EARLIER MISTAKE, BUT YOU KNOW, THIS FAMILY WENT THROUGH SOME HARD SHP AND THE CHILD SUFFERED, AND SO I THINK THAT'S A CASE WHERE YOU MIGHT SAY, WELL, YOU KNOW, NOBODY DIED, NOBODY WAS SEVERELY HARMED, BUT IT WAS BAD FOR THE FAMILY AND SO YOU KNOW, I THINK THAT'S WHERE I WOULD SAY APOLOGY IS NEEDED, PEDIATRICIAN FELT THAT TOO. WHEN YOU GET INTO THIS ISSUE OF SOMEBODY ELSE MADE A MISTAKE AND YOU'RE NOW WITH A PATIENT AND FAMILY, WE COULD DO ANOTHER SESSION ON THAT. BUT YEAH, I THINK IT'S THIS ISSUE OF FROM WHOSE PERSPECTIVE. AND YOU KNOW, IT DOESN'T HURT TO DO A SIMPLE -- YOU KNOW, I MEAN, WHEN YOU GO TO THE DOCTOR AND YOU WAIT FOUR HOURS AND THEN YOU FIND OUT YOU HAVE TO WAIT FOUR MORE HOURS, WOULD YOU WANT SOME KIND OF APOLOGY FOR WHAT HAPPENED. >> I WAS THINKING MAYBE ONE WAY TO ALSO ASK THESE QUESTIONS IS FOR THE PEOPLE WHO ENDORSE, SAY, THE TRAINED FACILITATOR/COMMUNICATOR, WOULD THEY SAY IN A CASE LIKE THIS, DON'T SAY ANYTHING, WE'VE GOT TO WHEEL IN OUR TRAINED COMMUNICATOR, OR DO THEY HAVE SOME THRESHOLD, NO, NO, JUST DO -- YOU JUST DISCLOSE AND THEN WHEN IT GETS PAST SOME THRESH HOLE OF THRESHOLD OF SIGNIFICANCE, THEN WE BRING IN ALL THIS MACHINERY OR SOMETHING AND WHAT'S GOING TO BE THE THRESHOLD FOR THAT. OKAY. MAYBE WE'LL GET MARION'S QUESTION, THEN LUNCH. LET ME JUST TAKE THIS TIME TO THANK LAURA AND ESPECIALLY REBECCA FOR SOLDIERING ON THROUGH HER VOCAL DIFFICULTIES AND HOPEFULLY WE'LL SEE YOU THE FIRST WEDNESDAY IN APRIL. THANKS. [APPLAUSE]