Patient Safety and

Full Disclosure:
What, Why, How,
and
Why not?
 Learning Objectives

• Define disclosure
• Describe the purpose of disclosure policies
• Identify the American Dental Association’s ethical position for disclosure
• List the barriers to disclosure
• Define “apology” laws
Jen’s Story
Full Disclosure : What?

- The patient and/or family will be informed,

- assured that corrective measures have been

implemented,

- and that additional steps are being taken to minimize

disability, death, inconvenience, or financial loss to the
patient or family.
 Full Disclosure Policy: Why?

 Address errors and near misses

 Support ethical obligations and provide transparency in patient care
 Reduce malpractice claims and liability costs
 Improve Patient Safety Efforts
 Full Disclosure Policy: Why?
Address Errors and Near Misses
• Johns Hopkins patient safety experts have calculated that more than 250,000
deaths per year are due to medical error in the U.S.

• Based on a total of 35,416,020 hospitalizations, 251,454 deaths stemmed from a

medical error, which the researchers say now translates to 9.5 percent of all deaths
each year in the U.S.

• The Harvard Medical Practice Study found that 3.7% of patients experienced an
adverse event during hospitalization
 Full Disclosure Policy: Why?
Ethical Responsibility
American Dental Association

Section 5, Veracity (“truthfulness”)

 Duty to be honest and trustworthy in their dealings with people.
 Respect the position of trust inherent in the dentist-patient relationship,
 Communicate truthfully and without deception, and maintaining intellectual integrity.

 Share the information that you have. Not sharing the information with the patient could
harm the trust that you are striving to develop between the two of you.
 Full Disclosure Policy: Why?
Ethical Responsibility
American Dental Association:
Section 4 Justice (fairness)

• Professionals have a duty to be fair in their dealings with patients,

colleagues, and society.
• Advisory Opinion 4.C.1 : Patients are dependent on the expertise of dentists
to know their oral health status.
 Full Disclosure Policy:Why?
Ethical Responsibility

• Fiduciary responsibility of the health care provider

• Supportive of patient Autonomy
• Allows open discussion for evaluation of adverse events
 Full Disclosure Policy:Why?
Transparency

• 43% of Patients who had sought litigation responded that they were
motivated by suspicion of a cover-up or for revenge.
• Respondents surveyed that they wanted health care providers to
acknowledge even minor events or near misses
 Full Disclosure Policy: Why?
Reduce malpractice claims and liability costs
University of Michigan Health Systems Full Disclosure Policy Outcomes:

• After full implementation of a disclosure-with-offer program, the average monthly rate of new claims
decreased from 7.03 to 4.52 per 100,000 patient encounters .
• The average monthly rate of lawsuits decreased from 2.13 to 0.75 per 100,000 patient encounters.
• Overall reduction in liability claims by 36% it was paying or defending
• Median time from claim reporting to resolution decreased from 1.36 to 0.95 years.
• Average monthly cost rates decreased for total liability, patient compensation, and non-compensation-
related legal costs.
 Full Disclosure Policy: Why?
Improve Patient Safety Efforts

• The rapid and deep investigations that can result from disclosure allows
institutions and providers to learn from errors and near misses.
• Improved safety efforts and successes will reduce future harm
 Full Disclosure Policy: How?

• Create a disclosure advisory committee

• Hire outside trainer
• Provide emotional support services for patients, families and providers
• Risk Management experts
• Transparent approach to changes in systems in response to error discovery
and mitigation efforts
 Full Disclosure Policy: How?
Create a Disclosure Advisory Committee
• Create a model for an apology and disclosure plan
• Apology laws prohibit a plaintiff introducing as evidence an apology made
by a physician if a mistake is alleged.
• The laws are aimed at reducing lawsuits, based on the reasoning that a
decision to file a suit is often made in anger, which can dissipated by acts of
compassion.
 Full Disclosure Policy: How?
Disclosure Advisory Committee
• Patients and families are promptly informed of serious adverse events.
• Those responsible for care of the patient may consult with risk
management or other members of the communication consultation team
before meeting with the patient and/or family.

• In this meeting, the health care provider discloses the known facts,
acknowledgment of the event, expressions of regret, and plans for care of
the patient.
 Full Disclosure Policy: How?
Disclosure Advisory Committee

• The patient and/or family are given assurances that the causes of the event will be
investigated and will be shared with them once more information is known.
• A commitment is made to remain in contact with the patient and/or family and to
be available for follow-up questions and requests for information.
• If an error caused the adverse event, an apology is offered, and a commitment is
made to find the cause of the error.
• Patients and families are informed of any corrective actions or changes in systems
or processes to prevent recurrence.
 Full Disclosure Policy : Why Not?

Barriers to Disclosure Policies

• Provider Discomfort
• Concerns about increased liability
• Attorney’s resistance to changing the status quo
• Challenges in coordinating insurance carriers
• Need supporting legislation (ie stronger apology laws)
 Full Disclosure Policy:
Closing Thoughts

System change is difficult, and the provider concerns are real.

evidence and piloted programs at the VA and Michigan Health Systems
demonstrate attainable results.
 Address medical errors and near misses
 Support ethical obligations and transparency in patient care
 Reduce malpractice claims and liability costs
 Improve patient safety efforts
Questions?
 References
• American Dental Association. American Dental Association principles of ethics and
code of professional conduct, with official advisory opinions revised to April 2012.
Available at: www.ada.org/sections/about/ pdfs/code_of_ethics_2012.pdf.
Accessed February 3, 2016. 2. Gallagher TH, Studdert D, Levinson W. Disclosing
harmful medical errors to patients. N Engl J Med. 2007;356(26):2713-2719
• Bell, S., Smulowitz, P., Woodward, A., Mello, M., Duva, A., Boothman, R., Sands, K.
(2012). Disclosure, apology, and offer programs: stakeholders’ views of barriers to and
strategies for broad implementation. The Milbank Quarterly. 90(4). 682-705.
• Hickson, G., Clayton, E., Githens, P., Sloan F. (1992). Factors that prompted families
to file medical malpractice claims following perinatal injuries. Journal of the
American Medical Association. 267. 1359-63.
• Johns Hopkins Report. (2016). Physicians advocate for how changes in how deaths
are reported. https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-
of-death/ . (accessed July 4, 2017).
 References

• Kachalia, A., Kaufman, S., Boothman R., Anderson, S., Welch, K., Saint, S.,
Rogers, M. (2010). Liability claims and costs before and after implantation of
a medical error disclosure program. Annals of Internal Medicine. 153(4). 213-
21. doi: 10.7326/0003-4819-153-4-201008170-00002.
• Kramen, S., Hamm, G. (1999). Risk management; extreme honesty may be
best policy. Medicine and Public Issues. 131(12). 963-7.
• Mahajan, R. (2010). Critical incident reporting and learning. British Journal of
Anesthesia. 105(1). 69-75. doi:10.1093/bja/aeq133
 References
• Kochar, P. JADA 147(4) Retrieved 8/31/2018 at http://jada.ada.org April 2016
• Peto, R., Tenerowicz, L., Benjamin, E., Morsi, D., Burger, P. (2009). One
system’s journey in creating a disclosure and apology program.The Joint
Commission Journal on Quality and Patient Safety.35(10). 487-496
• Saitta, S., Hodge, S. (2011). Physician apologies. Practical Lawyer. 2011:35-
43.
• Witman, A., Park, D., Hardin, S. (1996). How do patients want physicians to
handle mistakes? A survey of internal medicine patients in an academic
setting. Archives of Internal Medicine. 156. 2565-6.