Published in the May 2009 issue of Today’s Hospitalist
A GREAT DEAL OF INK has been devoted to whether ” and how “physicians should disclose medical errors to their patients. But little attention has been paid to where nurses fit into disclosure scenarios.
It may come as little surprise, then, that a recent study found that nurses routinely report being left out of even discussions with physicians about inpatient errors, let alone disclosure to patients. Those omissions may affect not only patient safety but nurse retention and morale.
That’s according to Sarah Shannon, PhD, RN, associate professor at the University of Washington School of Nursing in Seattle. Dr. Shannon is the lead author of the study, which was published in the January 2009 issue of The Joint Commission Journal on Quality and Patient Safety.
Dr. Shannon analyzed nurse focus groups held between 2004 and 2005. Her recommendations? Hospitals not only need to create and enforce error disclosure policies, but nurses need to be involved with physicians throughout the entire disclosure process. That includes helping to plan what will be discussed with patients as well as being a part of “either personally or through a nurse-manager surrogate “the actual disclosure session.
Dr. Shannon spoke with Today’s Hospitalist about the study.
Nurses in the focus groups claimed they routinely tell patients about errors for which they are responsible. What kind of events do they disclose?
Nurses said they were very comfortable talking about errors that they perceived were 100% within their control, like having given patients their medications late.
They weren’t comfortable talking about errors that may have been made by other members of the health care team, or errors that may have caused even moderate harm vs. just inconvenience. Those errors usually are caused by several factors, such as doctors’ orders or system errors.
What are the benefits of involving nurses in the disclosure process?
Having nurses involved helps everyone figure out what happened and why. Was this an error? What could we have done differently? Is there a systems change that could prevent this in the future, or a weakness in our procedures?
One big tip for doctors is to communicate as quickly as possible with the nursing staff and let them know what’s happened. If nurses can be a part of the pre-disclosure discussion, they can not only provide information to others on the team, but they can give patients correct information when asked.
Disclosure needs to be a team sport. Fortunately, the hospitalist model puts a premium on open communications and teamwork.
What are the dangers of excluding nurses?
When nurses are not involved, they may seem evasive when answering patient questions or give patients contradictory information. Or they may stall patients by asking families to write down their questions or set up a meeting with doctors.
When physicians don’t disclose errors and nurses have to deflect patient questions, that’s a very awkward position. These situations are distressing for nurses, and that may lead to burnout and possibly a decision to leave the profession.
Nurses feel strongly about this because they view it as their duty to inform patients. But they also want to be able to hear what is said by others during disclosure in part to avoid being unduly blamed for the error.
Are hospitals moving to more overt disclosure?
Though it’s still a controversial topic, making disclosure more transparent is an issue most hospitals are starting to experiment with or at least consider. Organizations including the Joint Commission and the American Hospital Association now give this a high profile.
Rather than addressing details about how a disclosure should go, hospitals should adopt policies similar to those for ethics consultations. That would allow clinicians to be openly involved in and raise questions or concerns about error disclosure.
To facilitate disclosure, hospitals might install an anonymous phone line for clinicians to call to report an error. Or there could be an open policy in which you’d speak to your supervisor and ask him or her to look into things. The point is to create a mechanism where anyone can initiate a discussion about a possible error, without fear of punishment or retribution.
Beyond setting policies, where should hospitals start?
Disclosure is a complex communication. Getting training or coaching is very important, and it’s a wise investment of organizational resources.
Some have skills in this kind of communication, but many don’t. Nurse managers should stand in for nurses who can’t be part of a disclosure because of scheduling. But nurse managers should also be acting as de facto coaches not only for nurses, but for inexperienced or novice physicians. Doctors don’t get disclosure training either.
It’s important for team members to get training as a team. Learning how to disclose an error is a skill, just like putting in an IV or a chest tube. It shouldn’t be the subject of a lecture but of a team practice session, ideally in a simulated environment with patient actors.
Ingrid Palmer is a freelance health care writer based in West Chester, Ohio.
