Talking with Patients and Families about Medical Error: A Guide for Education and Practice

10. Organizational Strategies for Improving Disclosure Practice

118 Improving communication in the aftermath of medical errors and adverse events will be successful only if it is part of a forwardlooking organizational approach to promoting a culture of safety. Likewise , patient safety efforts, to be efficacious, must be part of a comprehensive strategy of organizational learning, which can be defined as “the social production of inter-subjective experiences and organizational rules, structures and relationships, leading to changed organizational behavior .”168 In this chapter, we explore specific strategies for learning and change that health care organizations can use to develop effective disclosure programs as part of a robust patient safety agenda. Central to the process of organizational learning is the manner in which hospitals view, manage, and reflect on mistakes. Karl Weick, an organizational psychologist who has studied health care and other highreliability organizations, suggests that when organizations become successful at reducing error and improving safety, it is because they learn to appreciate the “aesthetics of imperfection.”169 These organizations figure out how to learn from mistakes through an open process of collaboration and reflection among key stakeholders—patients, family members, health care professionals, staff, and administrators. High-reliability organizations invested in safety learn to examine traditional habits, assumptions, and patterns of thinking and to gauge progress not only with quantitative metrics but also by how well they are measuring up to the core relational values we have described in this book—transparency, respect, accountability , continuity, and kindness. Optimal organizational learning depends on leadership at the highest levels but equally requires engagement and empowerment of staff at the TEN Organizational Strategies for Improving Disclosure Practice STRATEGIES FOR IMPROVING DISCLOSURE PRACTICE 119 levels of departments and frontline practice. Perhaps most important, it necessitates a heightened appreciation for a collaborative and relational form of learning that occurs in the context of appreciative and mutually respectful relationships. Within this framework, the knowledge and expertise of a high-functioning interdisciplinary team, for example, are understood to be a collective achievement, one that is greater than the sum of its individual parts. Individuals and Systems As health care organizations increasingly adopt more sophisticated ways of understanding and analyzing the systemic underpinnings of adverse events and medical errors, important questions arise about who is accountable for a given event and how accountability is best communicated to patients and families. When a serious event occurs, patients and families need to know that the clinicians most involved in their care are assuming responsibility for what has happened, and they need to hear from those clinicians directly. When an error is involved, they also need to receive an apology from those clinicians. However, most errors that occur in health care organizations are not the fault of just one individual; rather, they reflect systemic, not-yetaddressed problems in the way health care is delivered. The patient safety movement reminds us that most medical errors are systemic and that a large percentage of them are preventable. Therefore, significant reductions in the rate of medical errors are tied more fundamentally to organizational priorities and how organizations learn than they are to the behaviors or proclivities of individual clinicians. In this respect, the health care organization itself, as much as the individual clinician, needs to be accountable to patients and families when errors occur. These realities have implications for how errors should be explained to patients and families. The bottom line is that in any human enterprise like health care, when “human error” occurs, regardless of its cause, humans involved in that error must take responsibility and face the harmed party. In most cases, it is likely to be important to patients who have just suffered harm to know that the attending physician holds him- or herself responsible for the error because it occurred on his or her watch. At the 120 TALKING WITH PATIENTS AND FAMILIES ABOUT MEDICAL ERROR same time, the communication must provide patients and families with an accurate understanding of the likely interdependent and systemic nature of the error. In addition, it requires that those health care professionals who are most directly involved in the event (including, for example, nurses, pharmacists, and physicians in training) be accountable and in communication with the patient and family. Resolving this tension— requiring individuals to express responsibility for the failures of systems and requiring individuals to communicate accountability while giving patients and families an accurate explanation of the complexity of the failure—can be a daunting challenge. Furthermore, although disclosure...