Risk Management — Physician Disclosure of unexpected events or bad outcomes

Disclosure programs (also known as communication and resolution programs) encourage physicians to disclose unanticipated adverse patient events and outcomes. Adverse events are defined as patient injury resulting from medical error or systems failure. An adverse outcome is a result that differs from the anticipated result of a treatment or procedure and results in harm to the patient. The ethical rationale for disclosure is that the patient and his or her family have a right to know what happened.

Patients usually know when they have been injured as a consequence of an adverse outcome. When no one explains what happened, they assume a mistake is being concealed—and they become angry. Anger drives many malpractice claims. Disclosure often takes the edge off anger and is important in maintaining the physician-patient relationship.

Adverse outcome disclosure requires open, honest communication that includes full disclosure of the unanticipated event coupled with a genuine expression of concern that may include an apology— if appropriate. It is important to meet with the patient/family as soon as possible after the adverse outcome occurs. Since the cause of the event may not be immediately apparent, only the known medical facts are initially reviewed. It’s OK to say “I don’t know.” During the investigation, several meetings will occur and may include the patient or family.

The basic components of disclosure include:

  • Physician disclosure of the event to the patient and family, explaining what happened—or as much as is known at the time—and responding to questions.
  • Physician acceptance of overall responsibility for the patient’s care.
  • Empathizing with the patient, genuinely expressing concern and regret, and saying “I’m sorry this happened.” However, it isn’t appropriate to say “I’m sorry I did this” unless a clear-cut error has occurred that could have been prevented—and the person making the apology was responsible for the error.
  • Discussing the future consequences of the injury (hospitalization, medications, surgery, disability, etc.).
  • Explaining what is being done to prevent this from happening to another patient.

When an adverse outcome occurs, most physicians want to disclose the factors that contributed to the event. Sometimes, however, there may be reluctance to do so because of fear of a malpractice claim or concern that insurance coverage may be compromised by the disclosure.

The Doctors Company supports the principles of transparency and open discussion between physicians and their patients with disclosure when appropriate. However there is a difference between an “error” and an “adverse event,” and apologies are not appropriate for all adverse events (e.g., known complications).

The Doctors Company has its own disclosure program to assist physicians when disclosing adverse outcomes and complications that occur in facilities as well as in their office practices. These guidelines distinguish among three different types of adverse outcomes: a medical and/or system error, a known risk/complication or unforeseeable event, and an unexplained change in patient status or a newly diagnosed late-stage disease. Whether the event occurred in your office practice or in an inpatient or outpatient facility, take the following steps:

  1. Contact your patient safety risk manager to initiate a preliminary case review. Call us at (800) 421-2368, extension 1243, or e-mail us at patientsafety@thedoctors.com.
  2. Your patient safety risk manager will provide you with the complete disclosure protocol, review the protocol with you, guide you through the process, give you communication coaching and psychological support, answer your questions, and be your personal resource on disclosure.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctors Insurance Agency
215 S. Highway 101, Suite 117
Solana Beach, CA 92075
(858) 345-1370
(800) 464-2986