Here’s hoping the shocking revelation of a suburban Cincinnati hospital’s cover-up of the circumstances surrounding Neil Armstrong’s death will add new momentum to the movement for full transparency of medical errors.
It takes courage to admit a mistake, especially when the 82-year-old man dying on a gurney in your operating room was the first man to walk on the moon. It’s the kind of courage noticeably absent, not just at Fairfield Hospital, which is now part of Bon Secours Mercy Health, but at hospitals across America.
This is not just about the death of one patient in 2012 who happened to be a beloved American icon. This is about the tens of thousands of patients who die every year in American healthcare settings because of avoidable medical errors.
No one can say for certain whether Fairfield doctors did the wrong thing when they ordered an immediate bypass operation after Armstrong showed up on their doorstep with symptoms of heart disease. A few days after the operation, when his pacemaker leads were removed and severe bleeding ensued, they also may have erred when they sent him to the catheterization lab instead of the operating room.
But something went wrong. And when it does, questionable medical decisions need to be discussed openly and honestly among the physicians and clinical staff; between the physicians and family members; and by hospital officials and their safety advisers and regulators. None of that happened in this case, even though the benefits of such openness far outweigh the financial risk of increased medical malpractice litigation.
What are those benefits? Medical organizations that confront their mistakes honestly and change procedures and equipment accordingly develop a culture of constant improvement. This culture change is crucial if they’re to become high-performing healthcare providers. To do anything less puts future patients at risk.
Disclosure of errors also conforms with the ethical codes of an organization’s physicians and nurses. Nondisclosure does not. No one, on their first day in medical school, swears, “First, pretend no harm happened.”
While the evidence is anecdotal, systems adopting disclosure policies find family members are less likely to go to court. Moreover research shows medical malpractice claims, already in sharp decline, are highly concentrated among a small group of physicians. Constantly settling cases behind a veil of secrecy prevents organizations from confronting their poor performers with the need to either improve or change professions.
The hospital and attorneys for the Armstrong family ignored those benefits when they insisted on nondisclosure agreements after they reached a nearly $6 million settlement in 2014. At the time, family lawyers threatened to release their version of events at an upcoming moon landing commemoration unless a settlement was reached quickly.
While everyone’s bad behavior led to the worst possible outcome, the anonymous leaker to the New York Times understood the stakes. “The sender hoped the information would save other lives,” the paper reported.
The movement to link full disclosure of medical errors to an apology and restitution process is growing. It’s been adopted by 12 of 72 acute-care hospitals in Massachusetts. The Massachusetts Alliance for Communication and Resolution following Medical Injury uses principles created by the Veterans Health Administration in the 1990s, which were perfected at the University of Michigan in the early 2000s. The Agency for Healthcare Research and Quality has developed a toolkit called Candor for use by hospitals that want to go down this path.
A 2017 study by malpractice expert Michelle Mello of Stanford University showed the Massachusetts program has not led to an increase in malpractice claims, which is hospitals executives’ greatest fear. Today, about 100 hospital systems, with support from some state hospital associations, are considering implementation.
Hopefully, the publicity around the Armstrong case will encourage them to make the leap.