PUP 4931r Lecture Notes - Lecture 63: Breast Cancer Screening, Diabetes Care, Health Affairs
16 May 2018
School
Department
Course
Professor
Improving Patient Safety Through Transparency
Transparency regarding medical errors has proved more difficult to achieve.
Long way to go to achieve a culture of openly-identifying errors and conducting
investigations.
Goal of investigations would be to understand what happened and
facilitate open discussion to prevent similar mistakes from happening again.
Progress being made through pilot Disclosure, Apology, and Offer (DA&O)
programs
Take a principled approach to addressing errors, investigating, and
implementing interventions to prevent reoccurrence. Openly admit errors
to patients and make offers of compensation.
Let chips fall where they may when it comes to reputation & liability
Data from two of these programs revealed improved liability outcomes,
including a 60% decrease in legal and compensation costs in one program.
Downstream safety benefits from transparency.
No immediate wide spread adoption yet despite early program successes
(Kachalia, 2013)
Improving Patient Safety Through Transparency
Barriers slowing transparency progress:
Worry of financial risk & reputational risks- leading to declines in patient
volumes and revenue
Incentives to keep quiet are powerful when patient is not aware of the
error
Reluctance of clinicians-due to fear of losing their jobs because of human
error
Dealing with sensitive information
Under current law, when system-level errors result in payments to patients,
physicians may be reported to state boards as well as the National
Practitioner Data Bank (NPDB)
Worry about payments being made in cases in which no error occurred
(Kachalia, 2013)
Improving Patient Safety Through Transparency
Solutions?
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Transparency regarding medical errors has proved more difficult to achieve. Long way to go to achieve a culture of openly-identifying errors and conducting investigations. Goal of investigations would be to understand what happened and facilitate open discussion to prevent similar mistakes from happening again. Progress being made through pilot disclosure, apology, and offer (da&o) programs. Take a principled approach to addressing errors, investigating, and implementing interventions to prevent reoccurrence. Openly admit errors to patients and make offers of compensation. Let chips fall where they may when it comes to reputation & liability. Data from two of these programs revealed improved liability outcomes, including a 60% decrease in legal and compensation costs in one program. No immediate wide spread adoption yet despite early program successes (kachalia, 2013) Worry of financial risk & reputational risks- leading to declines in patient volumes and revenue. Incentives to keep quiet are powerful when patient is not aware of the error.
