《学术英语（医学）》拓展阅读资料：Taking with patients about other clinician errors

The NEW ENGLAND JOURNAL Of MEDICINE SOUNDING BOARD Talking with Patients about Other Clinicians'Errors Thomas H. Gallagher, M D, Michelle M. Mello, J D, Ph. D, Wendy Levinson, M.D Matthew K. Wynia, M.D., M. P.H., Ajit K. Sachdeva, M D, Lois Snyder Sulmasy, JD obert D. Truog, M.D., James Conway, M.A., Kathleen Mazor, Ed D, Alan Lembitz, MD Sigall K. Bell, M.D., Lauge Sokol-Hessner, M.D., Jo Shapiro, M.D Ann-Louise Puopolo, B.S.N., R.N., and Robert Arnold, MD You are a young neurologist Practicing in a small hospitaL. Existing guidelines emphasize the overall im- You admit a 55-year-old woman with hypertension and portance of disclosing errors, but(with the ex- ype 2 diabetes mellitus who had an embolic stroke at ception of the case study of the American Col- home On reviewing the patient's medical record, you no- lege of Physicians Ethics and Human Rights tice that she appears to have been in atrialfibrillation dur- Committee)16 they offer little guidance on dis- ing two electrocardiographic(ECG) tests during visits to closing others'mistakes; this lack of guidance the office of her primary care physician(PCP) for palpita- heightens clinicians' uncertainty about what to do tions. Her PCP, an internist who provides many of your Consequently, patients may be told little about referrals, read both ECGs as normal and attributed her these events, and opportunities to build trust, palpitations to"probable mitral-valve prolapse and anxi- ensure that learning occurs after errors, and gation may be lost. 17, 18 show the internist the ECGs and express concern that they We convened a working group of experts indicate atrial fibrillation. He politely disagrees and says patient safety, medical malpractice insurance and you are confused by noise from his old ECG machine. litigation, error disclosure, patient-provider com However, when you ask two cardiologists to look at the munication, professionalism, bioethics, and health ECGs, both immediately say "A-fib. "The internist re- policy. After the meeting, a subgroup of attendees a quests that you transfer the patient to his service(see the collaborated to refine these concepts and draft video, available with the full text of this article at this manuscript. Below, we describe recommen- A video and poll are NEJM.org) dations that extend existing guidelines for clini- available at cians and institutions on communicating with NEJM.org Although a consensus has been reached regard- patients about colleagues'harmful errors ng the ethical duty to communicate openly with patients who have been harmed by medical CHALLENGES WHEN IT IS NOT errors,1-6 physicians struggle to fulfill this re- “ MY ERROR sponsibility. -10 One particular challenge is that although the literature assumes the physician The rationales for disclosing harmful errors to providing the disclosure also committed the error, patients are compelling and well described. 19,20 health care today is delivered by complex groups Nonetheless, multiple barriers, including embar- of clinicians across multiple care settings. 11 In rassment, lack of confidence in one's disclosure addition, safety experts emphasize the role that skills, and mixed messages from institutions and system breakdowns play in adverse events. 12 Thus, malpractice insurers, make talking with patients many decisions about discussing errors with pa- about errors challenging. 1 Several distinctive as- tients involve situations in which other clinicians pects of disclosing harmful errors involving col were primarily responsible for the error. leagues intensify the difficulties Confronting the apparent error of a colleague One challenge is determining what happened raises challenging questions about whether an when a clinician was not directly involved in the error occurred, how the error arose, which pro- event in question. He or she may have little fessionals carry what responsibilities, and how firsthand knowledge about the event, and rele- to talk with the patient about the event. 4, 14 15 vant information in the medical record may be N ENGL J MED 369: 18 NEJM.ORG OCTOBER 31, 2013

sounding board The new england journal o f medicine 1752 n engl j med 369;18 nejm.org october 31, 2013 Talking with Patients about Other Clinicians’ Errors Thomas H. Gallagher, M.D., Michelle M. Mello, J.D., Ph.D., Wendy Levinson, M.D., Matthew K. Wynia, M.D., M.P.H., Ajit K. Sachdeva, M.D., Lois Snyder Sulmasy, J.D., Robert D. Truog, M.D., James Conway, M.A., Kathleen Mazor, Ed.D., Alan Lembitz, M.D., Sigall K. Bell, M.D., Lauge Sokol-Hessner, M.D., Jo Shapiro, M.D., Ann-Louise Puopolo, B.S.N., R.N., and Robert Arnold, M.D. You are a young neurologist practicing in a small hospital. You admit a 55-year-old woman with hypertension and type 2 diabetes mellitus who had an embolic stroke at home. On reviewing the patient’s medical record, you no￾tice that she appears to have been in atrial fibrillation dur￾ing two electrocardiographic (ECG) tests during visits to the office of her primary care physician (PCP) for palpita￾tions. Her PCP, an internist who provides many of your referrals, read both ECGs as normal and attributed her palpitations to “probable mitral-valve prolapse and anxi￾ety.” The patient is currently in normal sinus rhythm. You show the internist the ECGs and express concern that they indicate atrial fibrillation. He politely disagrees and says you are confused by noise from his old ECG machine. However, when you ask two cardiologists to look at the ECGs, both immediately say “A-fib.” The internist re￾quests that you transfer the patient to his service (see the video, available with the full text of this article at NEJM.org). Although a consensus has been reached regard￾ing the ethical duty to communicate openly with patients who have been harmed by medical errors,1-6 physicians struggle to fulfill this re￾sponsibility.7-10 One particular challenge is that although the literature assumes the physician providing the disclosure also committed the error, health care today is delivered by complex groups of clinicians across multiple care settings.11 In addition, safety experts emphasize the role that system breakdowns play in adverse events.12 Thus, many decisions about discussing errors with pa￾tients involve situations in which other clinicians were primarily responsible for the error.13 Confronting the apparent error of a colleague raises challenging questions about whether an error occurred, how the error arose, which pro￾fessionals carry what responsibilities, and how to talk with the patient about the event.4,14,15 Existing guidelines emphasize the overall im￾portance of disclosing errors, but (with the ex￾ception of the case study of the American Col￾lege of Physicians Ethics and Human Rights Committee)16 they offer little guidance on dis￾closing others’ mistakes; this lack of guidance heightens clinicians’ uncertainty about what to do. Consequently, patients may be told little about these events, and opportunities to build trust, ensure that learning occurs after errors, and avoid litigation may be lost.17,18 We convened a working group of experts in patient safety, medical malpractice insurance and litigation, error disclosure, patient–provider com￾munication, professionalism, bioethics, and health policy. After the meeting, a subgroup of attendees collaborated to refine these concepts and draft this manuscript. Below, we describe recommen￾dations that extend existing guidelines for clini￾cians and institutions on communicating with patients about colleagues’ harmful errors. Challenges When It Is Not “My Error” The rationales for disclosing harmful errors to patients are compelling and well described.19,20 Nonetheless, multiple barriers, including embar￾rassment, lack of confidence in one’s disclosure skills, and mixed messages from institutions and malpractice insurers, make talking with patients about errors challenging.21 Several distinctive as￾pects of disclosing harmful errors involving col￾leagues intensify the difficulties. One challenge is determining what happened when a clinician was not directly involved in the event in question. He or she may have little firsthand knowledge about the event, and rele￾vant information in the medical record may be A video and poll are available at NEJM.org

SOUNDING BOARD lacking. Beyond this, potential errors exist on a difficult to know what to say to the patient. cli- broad spectrum ranging from clinical decisions nicians may have legitimate concerns about de- that are "not what I would have done"but are stroying patients'trust in the involved colleague, within the standard of care to blatant errors especially if there is an ongoing care relation- that might even suggest a problem of profes- ship. There are also worries about triggering ional competence or proficiency. 22 litigation. Although some physicians might b One potential solution to this lack of infor- willing to subject a colleague to difficult conver mation is to talk with the involved colleague or sations with an angry patient or family, few will colleagues about what happened, whether it was find it easy to expose him or her to a potential a harmful error, and what, if anything, to tell malpractice suit. Most states protect some as the patient. In practice, however, fear of how a pects of disclosure conversations from use in liti- colleague will react, along with strong cultural gation, but this protection is incomplete and norms around loyalty, solidarity, and"tattling"3 might not extend to protecting an unrelated may deter such conversations. There is a natural third party to the disclosure. 26 And although re- reluctance to risk acquiring an unfavorable rep search suggests that good communication about utation with colleagues, disrupting relationships adverse events may reduce lawsuits, 7/ 28 data are among and within care teams, or harming one's lacking from studies to indicate how to disclose institution. Power differentials, including those others'errors while minimizing the risk that a associated with seniority, sex, and race, previous patient will initiate a claim. relationships with colleagues, interprofessional and other cultural differences, and in some cases WHERE DO WE GO FROM HERES dependence on colleagues for referrals all create complicated interpersonal dynamics. 24 Pragmat- The approach to communicating with patients ically, time constraints and coordinating meet- about other clinicians'errors should be deter ings with multiple clinicians pose additional mined through research into how this challenge barriers arises; the preferences of patients, clinicians, and Clinicians might be tempted to use the pa- institutions regarding handling such situations; tient's medical record to raise concerns about a and outcomes data regarding disclosure strate- potential error without initiating a direct con- gies. The following principles should be refined versation. Although this approach can avoid awk- as data and experience accumulate wardness and maintain the appearance of colle- giality, it arguably transgresses the norm of PATIENTS AND FAMILIES COME FIRST loyalty even more than a direct conversation, Although anxieties about damaging collegial re- since it can create evidence for a malpractice suit lationships loom large in situations of potential without allowing the colleague to dispel mis- error involving other clinicians, a patient's right conceptions. to honest information shared with compassion Although health care institutions could help about what happened to him or her is paramount. determine what happened and plan for disclo- Simply put, when disclosure is ethically required, sure, some clinicians will consider turning to the fact that it is difficult must not stand in the heir institution to be problematic. They may way. Patients and families should not bear the worry that reporting a concern to the institution burden of digging for information about prob might lead to an unpredictable, punitive cascade lems in their care or, on the other end of the spectrum, that no It must also be acknowledged that many action will be taken. 25 The clinicians and insti- families will need financial help after a serious tutions involved may have different malpractice error and will have a hard time accessing com- insurers that disagree about how to handle the pensation without information about what hap- event. Finally, many clinicians work in small pened. Clinicians rightly perceive the current practices without access to institutional resources medical liability system as flawed and under to help them figure out what happened and navi- standably worry that they may not be treated gate the disclosure conversation fairly should a patient file a claim. 29 But these Even when the facts surrounding harmful er- concerns do not obviate clinicians' duty to be ors seem clear, other challenges can make it truthful with patients; as professionals, clini- N ENGLJMED 369: 18 NEJM.ORG OCTOBER 31, 2013 1753

n engl j med 369;18 nejm.org october 31, 2013 1753 Sounding Board lacking. Beyond this, potential errors exist on a broad spectrum ranging from clinical decisions that are “not what I would have done” but are within the standard of care to blatant errors that might even suggest a problem of profes￾sional competence or proficiency.22 One potential solution to this lack of infor￾mation is to talk with the involved colleague or colleagues about what happened, whether it was a harmful error, and what, if anything, to tell the patient. In practice, however, fear of how a colleague will react, along with strong cultural norms around loyalty, solidarity, and “tattling”23 may deter such conversations. There is a natural reluctance to risk acquiring an unfavorable rep￾utation with colleagues, disrupting relationships among and within care teams, or harming one’s institution. Power differentials, including those associated with seniority, sex, and race, previous relationships with colleagues, interprofessional and other cultural differences, and in some cases, dependence on colleagues for referrals all create complicated interpersonal dynamics.24 Pragmat￾ically, time constraints and coordinating meet￾ings with multiple clinicians pose additional barriers. Clinicians might be tempted to use the pa￾tient’s medical record to raise concerns about a potential error without initiating a direct con￾versation. Although this approach can avoid awk￾wardness and maintain the appearance of colle￾giality, it arguably transgresses the norm of loyalty even more than a direct conversation, since it can create evidence for a malpractice suit without allowing the colleague to dispel mis￾conceptions. Although health care institutions could help determine what happened and plan for disclo￾sure, some clinicians will consider turning to their institution to be problematic. They may worry that reporting a concern to the institution might lead to an unpredictable, punitive cascade — or, on the other end of the spectrum, that no action will be taken.25 The clinicians and insti￾tutions involved may have different malpractice insurers that disagree about how to handle the event. Finally, many clinicians work in small practices without access to institutional resources to help them figure out what happened and navi￾gate the disclosure conversation. Even when the facts surrounding harmful er￾rors seem clear, other challenges can make it difficult to know what to say to the patient. Cli￾nicians may have legitimate concerns about de￾stroying patients’ trust in the involved colleague, especially if there is an ongoing care relation￾ship. There are also worries about triggering litigation. Although some physicians might be willing to subject a colleague to difficult conver￾sations with an angry patient or family, few will find it easy to expose him or her to a potential malpractice suit. Most states protect some as￾pects of disclosure conversations from use in liti￾gation, but this protection is incomplete and might not extend to protecting an unrelated third party to the disclosure.26 And although re￾search suggests that good communication about adverse events may reduce lawsuits,27,28 data are lacking from studies to indicate how to disclose others’ errors while minimizing the risk that a patient will initiate a claim. Where Do We Go from Here? The approach to communicating with patients about other clinicians’ errors should be deter￾mined through research into how this challenge arises; the preferences of patients, clinicians, and institutions regarding handling such situations; and outcomes data regarding disclosure strate￾gies. The following principles should be refined as data and experience accumulate. Patients and Families Come First Although anxieties about damaging collegial re￾lationships loom large in situations of potential error involving other clinicians, a patient’s right to honest information shared with compassion about what happened to him or her is paramount. Simply put, when disclosure is ethically required, the fact that it is difficult must not stand in the way. Patients and families should not bear the burden of digging for information about prob￾lems in their care. It must also be acknowledged that many families will need financial help after a serious error and will have a hard time accessing com￾pensation without information about what hap￾pened. Clinicians rightly perceive the current medical liability system as flawed and under￾standably worry that they may not be treated fairly should a patient file a claim.29 But these concerns do not obviate clinicians’ duty to be truthful with patients; as professionals, clini-

The NEW ENGLAND JOURNAL Of MEDICINE cians are expected to put the patient's needs challenges described below occur, it is appropri- above their own te to turn to the institution or health care or- ganization for assistance, if possible. EXPLORE, DO NOT IGNORE The challenge of disclosing another provid Before initiating a disclosure conversation about ers'error can arise in various situations. Table 1 a colleague's possible error, a clinician,'s first ob- outlines several common situations and propos- ligation is to obtain the facts. Patients'interests es a disclosure strategy for each. The recom- are not served by communicating inaccurate or mendations place a priority on patients receiv speculative information, and colleagues deserve ing needed information about harmful errors the chance to correct mistaken assumptions and through skillfully executed disclosure conversa- join disclosure conversations with their patients. tions. The recommendations regarding who is A strengthened commitment by clinicians to responsible for the disclosure were derived by "explore, don't ignore"potential errors is need- considering who has the strongest ongoing rela ed, and it will require that clinicians improve tionship with the patient, the best understand their ability to discuss quality issues with one ing of what happened and its implication for the another. This commitment is fundamental to patient, responsibility for the patient's current the self-regulation that lies at the heart of medi- care, and the most experience with disclosure in cal professionalism. Professional self-regulation complex situations (such as those involving should not be conceived of as something indi- multiple institutions). The proposed strategies vidual clinicians do, but rather as something also recognize the advantages of the disclosure the profession does collectively - and can being conducted jointly by the involved clini only do by sharing and acting on information cians. This avoids sending the patient mixed messages, ensures that key information is com- Ideally, we envision the process starting with municated clearly(rather than merely hinting at a colleague-to-colleague conversation about the error, so that the patient is left responsible what happened. Interacting directly with the in- for "connecting the dots"), and demonstrates volved colleague is part of our professional re- shared responsibility for transparency ponsibility. It is how we would hope a col- league would treat us, and it can promote INSTITUTIONS SHOULD LEAD learning. For a productive discussion to occur, it Although colleague-to-colleague discussions is essential to frame the conversation in ways should be the starting point for exploring poten- that minimize a colleague's defensiveness. A tial errors, institutions are ultimately responsible shift to a more proactive approach to discussing for ensuring that high-quality disclosure conver olleagues'potential errors should be balanced sations occur with patients, regardless of which by a willingness not to rush to judgment. Explo- clinicians were involved in the event. 4 Institu- rations should be undertaken with the assump- tional leadership is especially important when tion that persons who were not directly involved the patient had considerable harm, multiple cli- in the care have incomplete information, and nicians or other institutions were involved, com- the discussions should be approached with curi- munication among colleagues has broken down osity rather than accusations. 31 the colleagues disagree about what happened or The goal of the discussion with the involved whether disclosure is warranted, and concerns olleague is to establish what happened and, if are raised about conflict of interest (e.g, the col needed, how to communicate with the patient. league in question is a financial competitor). In The path forward will depend on the outcome stitutions that play a prominent role in such situ- of the peer-to-peer conversation. The colleagues ations ensure that a careful review of the event is may agree there was no harmful error, and the performed and that clinicians have not assumed process can stop. If they agree there was a that disclosure is someone else's responsibility harmful error, they can discuss what needs to and left the patient in the dark. be reported through institutional channels and Institutions should support conversations be- disclosed to the patient. The colleagues may tween clinicians as they seek to explore poten- also disagree about what happened or whether tial errors. Many institutions are developing disclosure is warranted. When these or other just-in-time disclosure coaching programs that 1754 N ENGL J MED 369: 18 NEJM.ORG OCTOBER 31, 2013

The new england journal o f medicine 1754 n engl j med 369;18 nejm.org october 31, 2013 cians are expected to put the patient’s needs above their own. Explore, Do Not Ignore Before initiating a disclosure conversation about a colleague’s possible error, a clinician’s first ob￾ligation is to obtain the facts. Patients’ interests are not served by communicating inaccurate or speculative information, and colleagues deserve the chance to correct mistaken assumptions and join disclosure conversations with their patients. A strengthened commitment by clinicians to “explore, don’t ignore” potential errors is need￾ed, and it will require that clinicians improve their ability to discuss quality issues with one another. This commitment is fundamental to the self-regulation that lies at the heart of medi￾cal professionalism. Professional self-regulation should not be conceived of as something indi￾vidual clinicians do, but rather as something the profession does collectively — and can only do by sharing and acting on information together.30 Ideally, we envision the process starting with a colleague-to-colleague conversation about what happened. Interacting directly with the in￾volved colleague is part of our professional re￾sponsibility. It is how we would hope a col￾league would treat us, and it can promote learning. For a productive discussion to occur, it is essential to frame the conversation in ways that minimize a colleague’s defensiveness. A shift to a more proactive approach to discussing colleagues’ potential errors should be balanced by a willingness not to rush to judgment. Explo￾rations should be undertaken with the assump￾tion that persons who were not directly involved in the care have incomplete information, and the discussions should be approached with curi￾osity rather than accusations.31 The goal of the discussion with the involved colleague is to establish what happened and, if needed, how to communicate with the patient. The path forward will depend on the outcome of the peer-to-peer conversation. The colleagues may agree there was no harmful error, and the process can stop. If they agree there was a harmful error, they can discuss what needs to be reported through institutional channels and disclosed to the patient. The colleagues may also disagree about what happened or whether disclosure is warranted. When these or other challenges described below occur, it is appropri￾ate to turn to the institution or health care or￾ganization for assistance, if possible. The challenge of disclosing another provid￾ers’ error can arise in various situations. Table 1 outlines several common situations and propos￾es a disclosure strategy for each. The recom￾mendations place a priority on patients receiv￾ing needed information about harmful errors through skillfully executed disclosure conversa￾tions. The recommendations regarding who is responsible for the disclosure were derived by considering who has the strongest ongoing rela￾tionship with the patient, the best understand￾ing of what happened and its implication for the patient, responsibility for the patient’s current care, and the most experience with disclosure in complex situations (such as those involving multiple institutions). The proposed strategies also recognize the advantages of the disclosure being conducted jointly by the involved clini￾cians. This avoids sending the patient mixed messages, ensures that key information is com￾municated clearly (rather than merely hinting at the error, so that the patient is left responsible for “connecting the dots”), and demonstrates shared responsibility for transparency. Institutions Should Lead Although colleague-to-colleague discussions should be the starting point for exploring poten￾tial errors, institutions are ultimately responsible for ensuring that high-quality disclosure conver￾sations occur with patients, regardless of which clinicians were involved in the event.4 Institu￾tional leadership is especially important when the patient had considerable harm, multiple cli￾nicians or other institutions were involved, com￾munication among colleagues has broken down, the colleagues disagree about what happened or whether disclosure is warranted, and concerns are raised about conflict of interest (e.g., the col￾league in question is a financial competitor). In￾stitutions that play a prominent role in such situ￾ations ensure that a careful review of the event is performed and that clinicians have not assumed that disclosure is someone else’s responsibility and left the patient in the dark. Institutions should support conversations be￾tween clinicians as they seek to explore poten￾tial errors. Many institutions are developing just-in-time disclosure coaching programs that

SOUNDING BOARD Table 1. Disclosing Harmful Errors in Common Situations Involving Other Clinicians. Participants in Potential Disclosur Error involving a clinician at your in. Joint responsibility, with both clini- A joint discuss that stitution who participating in disclosure is communicated to a patient with you(e.g,a con- conversation e patient and demonstrates a different service who previously ired for the patient) Error involving a trainee or interpro. Attending physician, with The attending physician leads the fessional colleague(e.g,a nurse ho made the error team and proba or pharmacist)on a primary team caring for the patien and the conversation itself(if ap. propriate al colleague could be disclosed tly by the attending physician Error involving a clinician at your in. Attending pl on primary service An ex ent Error unrelated to current care(e. g, Medical director(or other senior lead. The current treating clinician may not ra- er) at the institution currently car. be well suited to explain an error ing for the patient, after consulta unrelated to the present care. A with clinician involved in error. senior medical leader is better foreign body from p positioned to handle this complex Error involving a clinician at another the institution The medical director can provide the he current attend he error) as well as administrative ed to join the malpractice insur lave access to institutional or or ganizational resources. could help clinicians conduct respectful conver- handling errors involving colleagues by usin sations with colleagues about potential errors is the atrial fibrillation case to simulate how exist- a disclosure coach can facilitate peer-to-peer dis- ing quality, safety, and risk structures would help cussions, enabling each party to share his or her clinicians respond. Institutions could also use perspectives with less defensiveness. Role model- the case to identify opportunities for improve- ing by senior colleagues is also essential to ment. Such organizational preparation is prefer encourage meaningful discussions among clini- able to confronting these crises only when they Clans Existing formal venues for discussing con- Institutions should also strengthen "just cul cerns about quality such as morbidity-and-mor- tures, "which are"atmospheres of trust in tality conferences and peer-review committees people are encouraged, even rewarded, fo could also address questions about potential er- viding essential safety-related information rors involving colleagues. In addition, less for- but in which they are also clear about where the mal mechanisms such as a"curbside consult" line must be drawn between acceptable and un- with a quality expert or risk manager could help acceptable behavior. 32-34 Just cultures encourag niclans access the institutions event analysis clinicians to report adverse events and help ad- expertise(under the appropriate peer-review and dress hierarchy issues involving nurses and uality-improvement privileges) while minimiz- trainees that can obstruct the free flow of infor- milar resources will be needed for clinicians N ENGLJMED 369: 18 NEJM.ORG OCTOBER 31, 2013

n engl j med 369;18 nejm.org october 31, 2013 1755 Sounding Board could help clinicians conduct respectful conver￾sations with colleagues about potential errors.15 A disclosure coach can facilitate peer-to-peer dis￾cussions, enabling each party to share his or her perspectives with less defensiveness. Role model￾ing by senior colleagues is also essential to encourage meaningful discussions among clini￾cians. Existing formal venues for discussing con￾cerns about quality such as morbidity-and-mor￾tality conferences and peer-review committees could also address questions about potential er￾rors involving colleagues. In addition, less for￾mal mechanisms such as a “curbside consult” with a quality expert or risk manager could help clinicians access the institution’s event analysis expertise (under the appropriate peer-review and quality-improvement privileges) while minimiz￾ing clinicians’ fear of a punitive review process. Institutions could enhance their preparation for handling errors involving colleagues by using the atrial fibrillation case to simulate how exist￾ing quality, safety, and risk structures would help clinicians respond. Institutions could also use the case to identify opportunities for improve￾ment. Such organizational preparation is prefer￾able to confronting these crises only when they arise. Institutions should also strengthen “just cul￾tures,” which are “atmospheres of trust in which people are encouraged, even rewarded, for pro￾viding essential safety-related information — but in which they are also clear about where the line must be drawn between acceptable and un￾acceptable behavior.”32-34 Just cultures encourage clinicians to report adverse events and help ad￾dress hierarchy issues involving nurses and trainees that can obstruct the free flow of infor￾mation to the patient. Similar resources will be needed for clinicians Table 1. Disclosing Harmful Errors in Common Situations Involving Other Clinicians. Clinical Situation Participants in Potential Disclosure Rationale Error involving a clinician at your in￾stitution who is, or was, treating a patient with you (e.g., a con￾sulting specialist or colleague on a different service who previously cared for the patient) Joint responsibility, with both clini￾cians participating in disclosure conversation A joint discussion ensures that key information is communicated to the patient and demonstrates teamwork. Error involving a trainee or interpro￾fessional colleague (e.g., a nurse or pharmacist) on a primary team caring for the patient Attending physician, with the person who made the error encouraged to participate in disclosure planning and the conversation itself (if ap￾propriate) The attending physician leads the care team and probably has the most experience with disclosure. Errors involving solely an interprofession￾al colleague could be disclosed jointly by the attending physician and the relevant manager. Error involving a clinician at your in￾stitution who lacks direct contact with the patient (e.g., a radiolo￾gist or pathologist) Attending physician on primary service treating the patient, with the col￾league invited to join discussion An existing patient–provider relation￾ship facilitates disclosure conver￾sations. Error unrelated to current care (e.g., a radiologist reviewing a chest ra￾diograph of patient admitted for pneumonia notices a retained foreign body from previous ab￾dominal surgery) Medical director (or other senior lead￾er) at the institution currently car￾ing for the patient, after consulta￾tion with clinician involved in error, with the current attending physi￾cian invited to join the discussion The current treating clinician may not be well suited to explain an error unrelated to the present care. A senior medical leader is better positioned to handle this complex situation. Error involving a clinician at another institution Medical director at the institution currently caring for the patient, af￾ter consultation with the outside institution, with the current attend￾ing physician invited to join the discussion The medical director can provide the patient with clinical information (on the cause and implications of the error) as well as administrative perspective. A local medical society or malpractice insurer may provide support for physicians who do not have access to institutional or or￾ganizational resources

The NEW ENGLAND JOURNAL Of MEDICINE who do not have a strong institutional Supported by a grant from the Greenwall Foundation and by tion. These clinicians' liability insurer or the Risk Management Foundation of the Harvard Medical ers could provide similar support and Disclosure forms prowided by the authors are available with many insurers have expanded their disclosure the full text of this article at NEJMor vided by local medical societies and national for theig, JD, &ert Hanscom, J.D., Patrice Blair, MPH, Beth professional organizations. Patient-safety orga- Dunlap for project assistance, and the Oregon Medical Asso- nizations could fill this role over time. have the ciation for sharing the video associated with this article. advantage ng statutory protections for the From the Department of Medicine and the Department of Bio- confidentiality of information reported to them,(H G E the Department of Health policy and management and can help bridge the gap in cases that in- Harvard School of Public Health(M. M. M3, the Department of volve multiple institutions. 35 Social Medicine, Harvard Medical School (R nent of Medicine. Beth Israel Deaconess Medical Center (SKB, LS.-H- ) and the Division of Otolaryngology, Brigham WHAT SHOULD THE NEUROLOGIST DO? and Women's Hospital U.S. )-all in Boston; the Departme of Medicine, University of Toronto Toronto(w L ) the Institu The neurologist in our case is in an awkward sion of Education, American College of Surgeons(AKS) position. She is confident that the patient's inter- both in Chicago; the Center for Ethics and Professionalism nist did not diagnose atrial fibrillation, that this American College of Physicians, Philadelphia(LSS ); the Insti- error probably contributed to the patient's stroke, tute for Healthcare Improvement,Cambridge,MA(C);the and that disclosure to the patient is vital. The School, Worcester(. M. COPIC Insurance, Denver (AL): CVS internist has rebuffed her without assuaging her Caremark, Woonsocket, RI (A. LP ); and the Institute for Dod concerns. The neurologist's next step should be tor-Patient Communication and Section of Palliative Care and to tell the internist she plans to request a formal Medical Ethics, University of Pittsburgh School of Medicine cardiology consultation. With the diagnosis firm- ly in hand, she should communicate the findings cial Affairs. Code of medical ethics annotated current opinions to the internist and attempt to formulate a joint 2004-2005 ed. Chicago: American Medical Association, 2004. disclosure strategy. If the internist declines or 2. Snyder L. American College of Physicians Ethics Manual objects to the cardiology consult, the neurologist 3. Safe practices for better healthcare -2009 update: a should seek assistance from the institutions sensus report. Washington, DC: National Quality Forum, 2009 medical director or other senior ninistrative 4. Conway J, Federico F, Stewart K, Campbell M Respectful leader. The neurologist would be well served by managem snt of serious clinical adverse even 2nd ed IHe fn. support from a disclosure coach. Healthcare Improvement, 2011. Physicians-American Society of Internal CONCLUSIONS uropean Federation of Intermal Medicine When faced with a potential error involving an- Med 2002 136: 243-6 other health care worker, our conceptions of pro 6. The Full Disclosure Working Group. When things ponding to adverse events: a consensus statement of the Har- fessionalism should lead us to turn toward, rath- vard hospitals. Boston: Massachusetts Coalition for the preven- er than away from, involved colleagues. Although tion of Medical Errors, 2006 making the effort to understand what happened members"views on how clinicians enact and how they should and ensure appropriate communication with the enact incident disclosure: the 100 patient stories"qualitative patient may challenge traditional norms of col- study. BMJ2011343: 4423 legal behavior and involve additional demands survey shows that at least some physicians are not always open on clinicians'time, transparent disclosure of er- or honest with patients. Health Aff(Millwood)2012: 31:383-91. rors is a shared professional responsibility. only 9. Blendon R, DesRoches CM, Brodie M, et al. Views of prac a collective approach to accountability can fully 1933-40. meet the needs of patients and families after 10. Gallagher TH, Waterman AD, Ebers AG, Fraser VI,Levinson harmful medical errors W. Patients' and physicians'attitudes regarding the disclosure expressed are solely those of the authors and do not ll. Bell SK, Delbanco T, Anderson-Shaw L, McDonald TB, Gal- reflect the official positions of the institutions or organizations lagher TH. Accountability for medical error: moving beyond with which they are affiliated or the views of the project sponsors. blame to advocacy. Chest 2011: 140: 519-26 1756 N ENGL J MED 369: 18 NEJM.ORG OCTOBER 31, 2013

The new england journal o f medicine 1756 n engl j med 369;18 nejm.org october 31, 2013 who do not have a strong institutional connec￾tion. These clinicians’ liability insurer or insur￾ers could provide similar support and, indeed, many insurers have expanded their disclosure coaching resources. Support could also be pro￾vided by local medical societies and national professional organizations. Patient-safety orga￾nizations could fill this role over time, have the advantage of strong statutory protections for the confidentiality of information reported to them, and can help bridge the gap in cases that in￾volve multiple institutions.35 What Should the Neurologist Do? The neurologist in our case is in an awkward position. She is confident that the patient’s inter￾nist did not diagnose atrial fibrillation, that this error probably contributed to the patient’s stroke, and that disclosure to the patient is vital. The internist has rebuffed her without assuaging her concerns. The neurologist’s next step should be to tell the internist she plans to request a formal cardiology consultation. With the diagnosis firm￾ly in hand, she should communicate the findings to the internist and attempt to formulate a joint disclosure strategy. If the internist declines or objects to the cardiology consult, the neurologist should seek assistance from the institution’s medical director or other senior administrative leader. The neurologist would be well served by support from a disclosure coach. Conclusions When faced with a potential error involving an￾other health care worker, our conceptions of pro￾fessionalism should lead us to turn toward, rath￾er than away from, involved colleagues. Although making the effort to understand what happened and ensure appropriate communication with the patient may challenge traditional norms of col￾legial behavior and involve additional demands on clinicians’ time, transparent disclosure of er￾rors is a shared professional responsibility. Only a collective approach to accountability can fully meet the needs of patients and families after harmful medical errors. The views expressed are solely those of the authors and do not reflect the official positions of the institutions or organizations with which they are affiliated or the views of the project sponsors. Supported by a grant from the Greenwall Foundation and by the Risk Management Foundation of the Harvard Medical Institutions. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. We thank Robert Hanscom, J.D., Patrice Blair, M.P.H., Beth Cushing, J.D., Brent Tingle, J.D., and Carol Dembe, M.D., J.D., for their important contributions to our working group, Ben Dunlap for project assistance, and the Oregon Medical Asso￾ciation for sharing the video associated with this article. From the Department of Medicine and the Department of Bio￾ethics and Humanities, University of Washington, Seattle (T.H.G.); the Department of Health Policy and Management, Harvard School of Public Health (M.M.M.), the Department of Social Medicine, Harvard Medical School (R.D.T.), the Depart￾ment of Medicine, Beth Israel Deaconess Medical Center (S.K.B., L.S.-H.), and the Division of Otolaryngology, Brigham and Women’s Hospital (J.S.) — all in Boston; the Department of Medicine, University of Toronto, Toronto (W.L.); the Institute for Ethics, American Medical Association (M.K.W.), and the Di￾vision of Education, American College of Surgeons (A.K.S.) — both in Chicago; the Center for Ethics and Professionalism, American College of Physicians, Philadelphia (L.S.S.); the Insti￾tute for Healthcare Improvement, Cambridge, MA (J.C.); the Department of Medicine, University of Massachusetts Medical School, Worcester (K.M.); COPIC Insurance, Denver (A.L.); CVS Caremark, Woonsocket, RI (A.-L.P.); and the Institute for Doc￾tor–Patient Communication and Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh (R.A.). 1. 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SOUNDING BOARD 12. Institute of Medicine, Committee on Quality of Health Care 24. Srivastava R Speaking up - when doctors navigate medical in America. Crossing the quality chasm: a new health system for hierarchy. N Engl J Med 2013: 368: 302-5. 2lst century. on, DC: National Academy Press, 25. Call to action: safeguarding of he althea ethical or incompetent colleague. Hastings Cent Rep 1993: 23: -FINAL. pdf) 26. Mastroianni Ac. Mello mm er S, Hardy M, Gallagher 14. Lo B Resolving ethical dilemmas: a guide for clinicians. 3rd TH. The flaws in state'apology' and'disclosure'laws dilute their lliams w ded impact on malpractice suits. Health Aff (Millwood 15. Truog RD, Browning DM, Johnson JA, Gall H Talk. 201 010:29:1611-9 timore: 27. Kachalia A, Kaufman s. othman R, et al. Liability claims and costs before and after ican College of Physicians Ethics and Human Rights disclosure program. Ann Intern Med 2010; 153: 213.2 Committee Must you disclose mistakes made by other physicians? 28. Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld AcpInternistNovember2003(http://www.acpinternist.org/Jaegerj,Bostp.PatientcomplaintsandmalpracticeriskJaMa lives/ 2003/11/mistakes. htm). 2002:287:2951-7 17. DesRoches CM, Rao SR, Fromson JA, et al. Physicians' per- 29. Carrier ER, Reschovsky JD, Mello MM, Mayrell RC, Katz D eptions, preparedness for reporting, and related to Physicians'fears of malp assuaged by tort 1B d and incompetent colleagues. JAMA 2010; 304: 187-93. reforms. Health Aff(Millwood )2010: 29: 1585.92. ampbell EG, Regan S, Gruen RL, et al. Professionalism in 30. Lesser CS, Lucey CR, Egener B, Braddock CH IIL, Linas SL, medicine: results of a national survey of physicians. Ann Intern Levinson W. a behavioral and systems view of professionalism MA2010:304:27327. 19. Gallagher TH, Studdert D, Levinson W. Disclosing harmful 31. Rudolph JW, Simon R, Rivard P, Dufresne RL, Raemer DB. medical errors to patients. N Engl J Med 2007; 356: 2713.-9. Debriefing with good judgment: combining rigorous feedback 20. Wu AW, Cavanaugh TA, McPhee SL, Lo B, Micco GP. To tell with genuine inquiry. Anesthesiol Clin 2007: 25: 361-76. the truth: ethical and practic disclosing medical mis- 32. Marx D. Patient safety and the "just culture" health care executives. New York: Columbia University, 2001 Waterman AD, et al. Choosing 33. Marx D. Whack a mole: the price we pay for expecting per our words carefully: how physicians would disclose harmful fection. Plano, TX: By Your Side Studios, 2009. nedical errors to patients. Arch Intern Med 2006; 166: 1585-93 4. Wachter RM. Understanding patient safety. New York: Mc- 22. Wynia MK. The role of professionalism and self-regulation Graw-Hill, 2012. n detecting impaired or incompetent physicians. JAMA 35. Agency for Healthcare Research and Quality Patient Safety 2010;304:210-2 Organizationhomepage(http://www.pso.ahrqgovn) 23. Bosk CL. Forgive and remember: managing medical failure. DOL: 10.1056/NEJMsb1303119 nd ed. Chicago: Univer hicago Press, 2003. Copyright e AL MEDICI The Journal welcomes consideration of new submissions for Images in Clinical and procedures for submissions can be found on the Journals wel org. At the discretion of the editor, images that print version of the JoumaL, the electronic version, or both N ENGLJMED 369: 18 NEJM.ORG OCTOBER 31, 2013 7

n engl j med 369;18 nejm.org october 31, 2013 1757 12. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001. 13. Morreim EH. Am I my brother’s warden? Responding to the unethical or incompetent colleague. Hastings Cent Rep 1993;23: 19-27. 14. Lo B. Resolving ethical dilemmas: a guide for clinicians. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2005. 15. Truog RD, Browning DM, Johnson JA, Gallagher TH. Talk￾ing with patients and families about medical error. Baltimore: Johns Hopkins University Press, 2011. 16. American College of Physicians Ethics and Human Rights Committee. Must you disclose mistakes made by other physicians? ACP Internist. November 2003 (http://www.acpinternist.org/ archives/2003/11/mistakes.htm). 17. DesRoches CM, Rao SR, Fromson JA, et al. Physicians’ per￾ceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA 2010;304:187-93. 18. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med 2007;147:795-802. 19. Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med 2007;356:2713-9. 20. Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP. To tell the truth: ethical and practical issues in disclosing medical mis￾takes to patients. J Gen Intern Med 1997;12:770-5. 21. Gallagher TH, Garbutt JM, Waterman AD, et al. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Intern Med 2006;166:1585-93. 22. Wynia MK. The role of professionalism and self-regulation in detecting impaired or incompetent physicians. JAMA 2010;304:210-2. 23. Bosk CL. Forgive and remember: managing medical failure. 2nd ed. Chicago: University of Chicago Press, 2003. 24. Srivastava R. Speaking up — when doctors navigate medical hierarchy. N Engl J Med 2013;368:302-5. 25. Call to action: safeguarding the integrity of healthcare quality and safety systems. National Association of Healthcare Quality, 2012 (http://www.nahq.org/uploads/NAHQ_call_to_action _FINAL.pdf). 26. Mastroianni AC, Mello MM, Sommer S, Hardy M, Gallagher TH. The flaws in state ‘apology’ and ‘disclosure’ laws dilute their intended impact on malpractice suits. Health Aff (Millwood) 2010;29:1611-9. 27. Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med 2010;153:213-21. 28. Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld￾Jaeger J, Bost P. Patient complaints and malpractice risk. JAMA 2002;287:2951-7. 29. Carrier ER, Reschovsky JD, Mello MM, Mayrell RC, Katz D. Physicians’ fears of malpractice lawsuits are not assuaged by tort reforms. Health Aff (Millwood) 2010;29:1585-92. 30. Lesser CS, Lucey CR, Egener B, Braddock CH III, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA 2010;304:2732-7. 31. Rudolph JW, Simon R, Rivard P, Dufresne RL, Raemer DB. Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiol Clin 2007;25:361-76. 32. Marx D. Patient safety and the “just culture”: a primer for health care executives. New York: Columbia University, 2001. 33. Marx D. Whack a mole: the price we pay for expecting per￾fection. Plano, TX: By Your Side Studios, 2009. 34. Wachter RM. Understanding patient safety. New York: Mc￾Graw-Hill, 2012. 35. Agency for Healthcare Research and Quality Patient Safety Organization home page (http://www.pso.ahrq.gov/). DOI: 10.1056/NEJMsb1303119 Copyright © 2013 Massachusetts Medical Society. Sounding Board images in clinical medicine The Journal welcomes consideration of new submissions for Images in Clinical Medicine. Instructions for authors and procedures for submissions can be found on the Journal’s website at NEJM.org. At the discretion of the editor, images that are accepted for publication may appear in the print version of the Journal, the electronic version, or both

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