SINCE the time of the First Fleet, Australians have learnt that you don’t dob in a mate. But what if your mate is a colleague and you think what they’ve done has caused harm to a patient?
It’s more complex than simply saying the patient must be told the truth. If you think a colleague has made an error, not only do you have to consider what to say to the patient, but also what to say to your colleague. What if your colleague is your supervisor, or a competitor?
An article recently published in the New England Journal of Medicine (NEJM) outlines the challenges faced by practitioners when confronted by the apparent error of a colleague. Challenges include embarrassment, awkwardness and fear of how a colleague will react.
As well, a climate of increasing regulation of the medical profession, and the fear of legal or disciplinary action can make even the most insightful practitioner nervous and defensive.
Open disclosure has been promoted in the Australian Open Disclosure Framework, released by the Australian Commission on Safety and Quality in Health Care in March 2013, as a practice that benefits patients and clinicians involved in adverse events. Avant has supported open disclosure since the national open disclosure standard was first released in Australia in 2003.
Despite the passing of a decade, the notion of disclosing an error to a patient still causes concern to practitioners for many reasons, not the least of which is that admitting an error may be seen as an admission of liability. When the error is that of a colleague or has occurred at another institution, there are even more practical issues to consider.
Of the several steps in the disclosure process, the most important is to find out the facts.
At Avant we have seen many cases where a comment to a patient about the conduct of a colleague without all the facts has been the impetus for a claim or complaint. Many times we have heard a doctor lament “If only Dr X had rung me to find out what happened”.
On the other hand it sometimes might seem easier to put your head in the sand and just get on and treat the patient, but we would endorse the NEJM authors’ entreaty to “explore, do not ignore”.
In Avant’s experience, failure to deal with an adverse event in a timely and meaningful way is more likely to give rise to a claim or complaint.
The NEJM authors recommend a process that starts with a colleague-to-colleague conversation about what happened. This requires a commitment by practitioners to openly discuss quality issues; a commitment they say is “fundamental to the self-regulation that is at the heart of medical professionalism”.
Self-regulation is one of the traditional hallmarks of the practice of medicine. At the level of the individual, self-regulation relies on practitioners having the insight to realise when they have made an error and to reflect on it. Self-regulation encourages a supportive culture that recognises that mistakes happen and lessons can be learnt from them.
Although the new Open Disclosure Framework does not deal directly with errors by colleagues, it recognises that they do occur and outlines steps for determining whether the adverse event has been acknowledged and the open disclosure process has started. If it hasn’t, it should be initiated after consultation and in collaboration with the individuals and organisations involved. This process is consistent with the NEJM authors’ recommendations for a productive and collaborative approach to errors by colleagues.
In a society that expects medicine to cure all, it is not always easy for a practitioner to admit they have made a mistake.
However, a supportive culture, where communication is open and honest, adverse outcomes are discussed and lessons learned, plays a vital role in maintaining trust in our doctors and the health care system.
Georgie Haysom is the head of advocacy at Avant.