Best Practices: Addressing errors with Candor

Is it really better to say you're sorry? From the institutional perspective of a hospital, the answer is typically a resounding no.

Apologizing for medical errors invokes fears that the gesture will be construed as an admission of guilt that leads to a massive payout. But a small cohort of providers is pushing back against that idea. Backed by the Agency for Healthcare Research and Quality, they have been using a process called Candor, short for communication and optimal resolution.

They say it improves patient safety and quality of care, and they also hope it can save hospitals money.

“If we can't be open and honest about these events, we're never going to learn from them and be able to fix our processes and systems,” said Dr. David Mayer, vice president for quality and safety at MedStar Health, eight of whose 10 hospitals, located in the Baltimore-Washington area, participated in a pilot program for the Candor toolkit.

In the past four years, MedStar has lowered serious safety events by almost 60%, Mayer said. He said he could not attribute that reduction entirely to Candor, however, as the hospital had simultaneously been carrying out other techniques to reduce risk and preventable medical harm.

The Candor toolkit contains videos, PowerPoint presentations and other documents explaining a variety of activities, including how to hold conversations with patients and families and how to implement disclosure programs across an institution.

The priority with disclosure programs was to improve patient safety and reduce errors, Mayer said, although saving money is also a motive. “Our claims have been reduced because we come to this solution early,” he said. “As long as the lawyer on the other side is truly willing to work with us and come up with a fair and equitable remedy, we settle those cases quickly.”

MedStar defines medical error broadly, as whenever “care goes in the direction that we hadn't anticipated,” Mayer said, and its goal is to tell a patient or family within 15 minutes of a medical error occurring.

Patients in hospitals experience harm from errors including foreign objects left inside during surgery, procedures performed on the wrong part of the body, and incorrect medications or doses.

“Many times, that first conversation is, 'We don't know what happened, but we promise we will figure out what happened, and as we figure out what happened we will share it with you, and if appropriate, we will apologize,'” Mayer said.

Some programs are more open about trying to lower legal costs.

The University of Michigan touts its model as having slashed legal costs by more than half since 1997 and having saved its health system $2 million in the first year of the program, which began in 2001.

Candor is “the best program that no one's ever heard of,” said Dr. Steve Kraman, a professor at the University of Kentucky. He pioneered what's often cited as the earliest disclosure initiative, in 1987, when he headed up the risk- management committee at a Veterans Affairs medical center in Lexington, Ky.

A patient had died because of a medical error, and the family had no idea. The doctors decided to tell them. The hospital handled every subsequent case the same way, a policy that remained unwritten for another decade, Kraman said.

The $1.33 million that the Lexington center paid out in total malpractice claims and liability payments from 1990 through 1996 put it in the bottom third of 35 other VA facilities, although it ranked in the top third for the number of claims filed. “People want to be treated honestly,” Kraman said.

But not everyone sees such radical openness as beneficial.

Dr. Victor Cotton, a lawyer and president of the Hershey, Pa.-based healthcare consultancy Law and Medicine, criticized the idea of transparency for the sake of transparency. “The goal should be to improve patient care, and I don't see how these programs do that.”

In particular, Cotton questioned whether hospitals that adopted the practice actually incurred any savings, because the idea that people would accept an apology over a pile of money was “counterintuitive.”

Still, Julia Hallisy, the founder and president of the Empowered Patient Coalition, an advocacy group that has surveyed patients on adverse medical events, warned that a lack of transparency jeopardizes something far more important. Most patients eventually heal physically from medical errors, but the emotional trauma often has lasting, devastating repercussions.

“The reality is that providers can do everything right and still have poor patient outcomes,” Hallisy said. “We've done a very poor job of explaining that to the public.”

CORRECTION:

This story has been updated to reflect that in the past four years, MedStar has seen a decrease of 60% in serious safety events.