5 Tips for Radiology Error Disclosure

CHICAGO - Mistakes were made. Errors have occurred. Unanticipated outcomes have been experienced. Translation: I screwed up.

That’s hard enough to say in your personal life. But in your professional world, where lives are on the line and a mistake could make your malpractice insurance go through the roof? It’s nearly impossible.

But following RSNA 2012’s “Patients First” dictate, that has to change. And even if you don’t want to disclose mistakes, the rise of patient portals and over-reading means errors are less likely to be swept under the rug. Sorry, folks, you’re going to have to learn to say, “I’m sorry.”

It doesn’t have to be traumatic. The interactive session "Disclosure of Medical Error in Radiology" on Monday explored some myths and gave pointers for surviving the disclosure process.

Tip 1: It’s not as dangerous as you think.

Malpractice fears are “the No. 1 imagined barrier to disclosure,” said Thomas Gallagher, MD, an internist and professor in the Department of Bioethics and Humanities at the University of Washington. That doesn’t mean physicians aren’t at all worried about malpractice - just that they may use that as an excuse to mask their fears.

As evidence, Gallagher points to New Zealand, which has no-fault medical laws. Physicians can’t be sued for malpractice there, and they’re just as unwilling to want to tell patients they were wrong.

In fact, proactively disclosing mistakes can protect you: The University of Michigan is one of many academic institutions that have been doing this for several years. They’ve cut their malpractice claims in half.

Tip 2: It’s not about faking sincerity.

Have you ever had kid confess a crime and then expect that to make everything better? Nothing torpedoes their apology like a huffy “I said I was sorry!”

It’s just counterproductive when a doctor does it.

“This issue is at the heart of the whole thing: dancing around the topic, not taking personal responsibility, giving a half apology but not a real apology,” said David Browning ,MSW, senior scholar and co-director of patient safety and quality initiatives at the Institute for Professionalism and Ethical Practice at Children’s Hospital Boston. Unless you mean it, it won’t make a difference.

And think about when that kid apologized with his mom standing behind him, arms crossed and foot tapping. That’s what it looks like when your disclosure is prompted by your malpractice-insurance provider. “The places where this has been most successful are the places where it’s really been seen as a component of professionalism that physicians have taken the initiative on,” Brown said.

Tip 3: It’s not about you.

Confession is good for the soul, but your soul and your feelings aren’t the point of this exercise. The patient’s are.

“You can never assume that at the end of an interview when you disclose what happened that you’re going to feel better,” Brown said. “You may feel worse. You may feel frustrated because no matter what you say, no matter how much empathy you have, they may be quite angry, and they may end the interview that way. If you put yourself in the patient’s shoes, that’s a legitimate place for them to be.”

So yes, everyone makes mistakes, nobody’s perfect, you did your best and you feel bad. A disclosure meeting with a patient isn’t the place to bring that up. You’re not the one who’s sick and scared. The patient is.

Tip 4: It’s not a spur-of-the-moment thing.

Maybe you’re great with patients. Maybe you ooze empathy. That doesn’t mean you should jump into a disclosure meeting as soon as you spot an error.

“When we look at disclosures that have gone wrong… [the biggest reason is] lack of planning and preparation,” Gallagher said. “You’re trying to balance two competing things here: One is trying to be transparent in a timely way, but you want to have a process to think carefully about what happened here, what am I going to say to the patient and how are we going to do this.”

That’s where just-in-time coaching comes in. You may be able to talk with someone at your malpractice-insurance company, or you may be able to run things by a colleague before you go to a patient. “It’s so helpful to go in with a list and a plan for ‘What are the key things I want to share with the patient and how do I manage the patient’s emotions,’” Gallagher said.

Tip 5:  It’s not defined yet.

When is an error really an error? Sometimes it’s obvious. You missed a mass that you should have caught. Other times, it’s less clear-cut.

Take a false-positive result on a mammogram. Maybe your colleagues reviewed your film and said no, they wouldn’t have recommended a biopsy for that. Well, it’s too late; the patient has already gone through a biopsy and gotten good news. Do you tell her it wasn’t a necessary procedure?

“We need to really be able to define clear guidelines for when is an error an error,” said Constance Lehman MD, PhD, professor and vice chair of radiology and section head of breast imaging at the University of Washington. “Is it different when it impacts a patient, or to what degree it impacts a patient?” Good question - one we don’t have an answer for yet.

That’s why radiology needs professional guidelines for disclosure. “This is not the sort of conversation that lends itself to a cookbook,” Gallagher said, “but I think practicing radiologists would benefit from some guidance about what are best practices in this area.”