“Culture of Candour” trumps “Duty of Candour”

The Government of England recently passed legislation requiring institutions to inform patients, and/or other appropriate parties, of instances where patients have been harmed as a result of “errors”. The term “error” has always troubled me because it imparts a flavour of blame. Although many patient safety incidents may be due to “errors”, others arise due to system and/or human inefficiencies or insufficiencies; and often numerous contributing factors align in the final causality of harmful incidents.

In my view, it is a failure of our professional obligations that has contributed to legislation becoming necessary and appropriate, in the minds of some, to create a requirement for candour. We have always had an obligation to be candid, but too often we have failed to live up to that standard. We have failed to build and sustain a “Culture of Candour¹”. We have too often let our patients down and should be ashamed. Perhaps, we have been somewhat arrogant and as a colleague once told me, “arrogance is the eggshell over fear and the tender side².”

The relationship between clinicians and patients is based upon a sacred trust. Best outcomes can only be achieved if clinicians and patients are working together, relying on each other on a journey toward improved health and healthcare outcomes. Clinicians and patients are the key stakeholders on the front lines of healthcare, each is an expert in their own ways. Even when things go wrong there is still an underlying obligation of trust. Sustaining this trust is essential, our patients deserve nothing less; and disclosure is the tool that helps us all to navigate these challenges. Early disclosure can reduce the frequency and magnitude of malpractice claims^3,4.

Case Study – Disclosure in a Culture of Candour:

An elderly, obese woman had been hospitalized after a right hip fracture, complicated by a postoperative deep vein thrombosis in her right calf. At the beginning of the second week of hospitalization, it was noted that the patient had developed a Stage 2 sacral pressure ulcer. The patient had not received timely peri-operative anticoagulation, and nursing staff had not monitored her and worked sufficiently to prevent the development of the pressure ulcer. The patient developed a deep cellulitis, thus prolonging her hospitalization and resulting in much pain.

The senior physician and nurse met with the patient and her husband, both of whom had limited education and medical knowledge and seemed bewildered by the medical environment. A patient advocate, a trained hospital representative whose role was to help them both navigate the myriad of complex issues, participated in the disclosure discussions.

To start, the doctor apologized to the patient and her husband. He stated that two separate incidents had contributed to her difficulties. She had not been prescribed perioperative anticoagulants, as was the usual custom, and also the nursing staff had not done enough to prevent the pressure ulcer. He explained that there were likely multiple contributing factors to both of these incidents, and that an investigation would be undertaken to identify opportunities to improve care for all patients and to prevent this from happening to others. He promised that the hospital would do everything in its power to provide the patient with safe, high quality care and that he and his team fully recognized that they had not done as well as they should have. The doctor promised to provide additional feedback regarding the investigation.

Most important, the doctor asked the patient and her husband if there was anything else he or his staff could do at this point and he listened attentively. He even offered to transfer the patient’s care to another team of doctors and nurses or even to another hospital. At the end of the conversation, he sat quietly waiting for any final expressions or sentiments. The patient and her husband thanked the doctor for his honesty.

The patient remained hospitalized for two additional weeks. She and her husband did not file complaints with the regional health authority, nor did they file a malpractice claim against the hospital or the doctors involved in her care.

Bridge Lesson: Trumps rule the day and culture trumps legislation for every hand played.

Your deal…

Ref:

1. Comment attributed to Dr. Donald Berwick, MD, MPP at the IHI conference, Orlando, FL, USA, December 2014.
2. Quote attributed to Ms Geri Amori, PhD, DFASHRM at the ASHRM conference, Anaheim, CA, USA, October 2014.
3. Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. (Available on www.IHI.org).
4. Kachalia, A, Kaufman S, Boothman R. et al. Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program. Ann Intern Med. 2010:153:213-221.