Commentary – Being open
By John Tiernan, MPS Executive Director, Member Engagement
Sadly things do go wrong in medicine. We can’t be totally confident about how frequently things go wrong, but they are not a rare occurrence.
For many years a culture of denial existed, where doctors were heroes who never have adverse outcomes. These expectations led patients to demand perfection and perceive adverse outcomes as unacceptable even when the literature suggests that as many as 50% are not avoidable. The fear of openness is often driven by a blame culture where the doctor is disproportionally singled out for sanction, regardless of the multifactorial causes of some of these events.
The real challenge is how to change this culture to one where we move from disproportionate blame to one of fair accountability or a just culture, where the emphasis is on learning from adverse events rather than finding someone to blame. The learning culture is balanced by the profession taking accountability when mistakes are made.
A good starting point is encouraging openness after an adverse event has occurred. When something has gone wrong be open and candid with the patient – it is part of the ongoing therapeutic relationship. Say sorry for what has happened and talk honestly with them – don’t run away or deny what’s happened. It isn’t always easy but it is the right thing to do.
Examining significant events and exploring adverse outcomes is not always an admission of bad practice – it is, however, an essential part of good practice.
Being open can also reduce the risk of complaints and claims. For many patients who have suffered an injury, turning to the law is often a last resort; patients go down this route because they feel it is the only way to have their questions answered.
There is a large amount of evidence that suggests that people lodge a complaint or a claim against a doctor, not primarily because of their injury, but because they’re angry at what happened and want answers.
Which is more professional? To refuse to acknowledge an adverse outcome and cling to the belief that you are incapable of having one, or to acknowledge it, manage it ethically and professionally and, most of all, learn from it?
Which sort of professional would you rather be treated by?
"We’re moving from paternalism with patients – let the doctor tell you what’s right for you – to an openness and a patient partnering, where the patient not only has a right to know, but we want them to know."
Lucian L Leape MD
Adjunct Professor, Health Policy, Harvard School of Public Health
"Don’t think we can become safer secretly. There’s some very inescapable connection between openness and honesty and disclosure and involvement, confession, apology... all acts of openness in building a safe culture. I think this idea of transparency and openness is an essential part of our future."
Dr Donald Berwick
MD, MPP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement
"Information about errors and adverse events, harmful outcomes in healthcare, has very seldom been studied openly; it’s been treated as a nuisance, something we don’t want to know about, an occasion for shame, guilt, and other sorts of problems. In the last few years in healthcare we’ve come to realise that it can also be – if treated properly – a resource, and an essential way of achieving a safe culture."
Professor Charles Vincent
Professor of Psychology, Emeritus Professor of Clinical Safety at Imperial College London, Imperial College, London
"When something goes wrong, you need to lose sleep over it. Why did it happen? Do I understand what happened here? Have I made sure that I know the reasons this happened? What can I do to prevent it? Have I said sorry to the patient? Have I involved the patient in this situation? Have I talked to staff? I think that’s a really important obligation of doctors."
Professor Mayur Lakhani
GP and Chairman of the National Council for Palliative Care, UK
"Medical teams are human. Medical teams are driven to succeed and have the needs of the patient at heart. They need to be pre-occupied with the possibility that they will make errors. The team leaders, usually consultants, must understand that they will make mistakes and try to break rules in order to achieve results. The safety net is their team who must trap or mitigate the consequences of such errors or violations. Research shows that if the leader briefs the team in an open, interactive and inclusive manner then team members will speak up in an assertive manner when the situation demands."
Former British Airways training captain and human factors expert
- Note to non-UK readers: the Health Select Committee is part of the UK parliament, and oversees the operations of the UK Department of Health.
Here is a link to the Health Select Committee report: www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/151/151we22.h