Sue Sheridan's voice cracked as she recalled two preventable medical errors that changed her life forever and for the worse.
In 1995, Sheridan and her husband, Pat, were relieved to hear that a magnetic resonance imaging scan showed their newborn son, Cal, was healthy. Sixteen months later, they learned Cal had suffered brain damage because of undetected jaundice. The MRI scan that they had been told was normal actually showed that abnormal signs, which should have led to more tests and ultimately treatment for the jaundice, Sheridan said.
A few years later, doctors removed a cancerous tumor from the back of Pat's skull. He should have undergone subsequent radiation therapy but didn't, because the pathology report that identified the tumor as cancerous was misplaced, Sheridan said. Pat died in 2002 after the cancer returned and spread to his spine.
"The errors were unintentional mistakes. The decisions not to disclose them were calculated and deliberate," said Sheridan, co-founder of Consumers Advancing Patient Safety, or CAPS, an Eagle, Idaho-based group, and a panelist at the Patient Safety Congress last week in Orlando, Fla.
Admitting fault, long taboo for providers, may prove the best course of action, reducing lawsuits and preserving patient trust -- it's also the right thing to do, speakers at the gathering said. About 1,300 healthcare professionals attended the three-day meeting sponsored by the National Patient Safety Foundation.
According to a study at the University of Massachusetts Medical School, when providers disclosed fault, patients had greater trust in their caregivers and were no more likely to seek legal advice than in cases where fault was not disclosed, said Kathleen Mazor, an assistant professor who conducted the study and presented early results at the conference.
Another benefit of admitting fault is the healing effect on providers, who are often devastated by the effects of medical errors, said Lucian Leape, an adjunct professor of health policy at the Harvard School of Public Health.
But while full disclosure is an ideal often talked about at conferences, it's seldom practiced, Leape said.
In addition to fearing litigation, many providers fear they may be stuck with the cost of care for patients injured by adverse events, said Jeffrey Cooper, chairman of the research department at the National Patient Safety Foundation.
Cooper said he's not sure who should pay -- the provider or insurer -- when preventable errors lead to more medical care. But, he said, "The patient shouldn't have to."
The issue grows murkier if the event occurred even when the medical team did everything right. One possibility is a provider-funded "no fault" compensation pool, with the worst-performing providers making higher contributions, said David Lawrence, conference co-chairman.
Sheridan, who had founded Consumers Advancing Patient Safety with her husband, settled his case without litigation. It took a decision from the Idaho Supreme Court for her to win a settlement for the cost of Cal's care, which she estimated at $4 million to $7 million during the first five years of his life.
Putting in place systems to justly compensate injured patients, without necessarily having to involve the courts, is one of CAPS' goals. Among the others are a national consumer-led patient-safety board and a national patient-safety awareness campaign emphasizing trust and open communication.
Shortly before Pat died, Sheridan said, he told her: "Whatever you do, do not give up on patient safety." Looking into the crowd of attendees at her panel session, Sheridan said, "I ask you to do the same."