A system of medical error disclosure.

External mandates for medical error disclosure are often justified by potential cost savings, the belief in individual moral obligations in health care, and the concept that patients have rights and providers have responsibilities. Such an approach does not recognise the systems nature of error and outcomes and the important quality role disclosure can play in a system of medical error disclosure. Systems concepts, the patient-provider partnership, and overall quality of care can be enhanced using a system of disclosure that provides for education about the systems nature of error, fulfills the delivery system philosophy of mutual respect, and integrates the patient and his/her family as a partner in the error reduction enterprise. Such a system can result using clear disclosure policies and procedures sensitive to patient and family needs, open communications with concerned, committed, and compassionate system representatives, and use of mediation methods that foster communication, allow for venting, and are flexible in their approach to resolving conflict, including using apology. Although a system may also result in conflict resolution costs, more importantly it may foster and solidify a team approach to reducing errors and promoting patient safety.

Other people's money: a reply to the Joint Commission.

In a response to Professor Liang's earlier article expressing concern regarding the Joint Commission's Sentinel Event Policy ("SEP"), the General Counsel of the Joint Commission disagreed with the criticisms of the SEP. In this Comment, Professor Liang replies to the Commission's position, indicates that resources devoted to legal issues created by the SEP are not available for patient safety, and that the goal of patient safety may be better served by focusing on near misses rather than sentinel events. Finally, he concludes that the Joint Commission and its critics have the same ultimate goal, and that a cooperative approach which includes federal legislation to protect safety information is essential.

Creating problems as part of the "solution": the JCAHO Sentinel Event Policy, legal issues, and patient safety.

The recently reported number of patient deaths attributable to medical errors is staggering. In response to this crisis, the Joint Commission on Accreditation of Healthcare Organizations ("JCAHO") proposed its Sentinel Event Policy. The policy mandates self-reporting by hospitals accredited by the JCAHO. This Article argues that the JCAHO's policy shows an inattention to the legal realities of discovery and absence of immunity. Until the JCAHO addresses these issues, self-reporting will have limited success. This Article suggests that to promote patient safety, self-regulatory reports should go to a neutral, nonsanctioning third party, an approach adopted from aviation's highly successful reporting system.

Clinical assessment of malpractice case scenarios in an anesthesiology department.

STUDY OBJECTIVE: To determine whether anesthesiologists agree with each other when assessing actual malpractice clinical scenarios, whether their assessments comport with the actual malpractice verdicts, and whether they can accurately guess jury verdicts. DESIGN: Survey study requesting anesthesiologists to review 12 malpractice case scenarios, administered twice. SETTING: Academic medical center department of anesthesiology. MEASUREMENTS AND MAIN RESULTS: Mean interphysician agreement, mean Likert values assessing relative negligence, mean agreement with jury verdicts, mean success at predicting actual jury verdicts for 12 actual jury verdict case scenarios. Respondent anesthesiologists appeared homogeneous by training and years of experience. They showed high (> 80%) agreement among themselves in their assessments of the malpractice case scenarios over the two administrations (p = 0.13). In addition, mean Likert values as to relative negligence assessments by respondent anesthesiologists were not significantly different between administrations by case (p = 0.09 to 1.00). However, of the eight cases with complete or virtually complete agreement between respondent anesthesiologists, three (37.5%) disagreed with the verdict rendered by the actual juries. In addition, anesthesiologists showed significant disagreement (> 30%) among themselves in four of the case scenarios, indicating there may not be agreement regarding the standard of care in these clinical circumstances. Finally, anesthesiologists predicted jury verdicts poorly, with success rates of 50% or less in seven of the 12 case scenarios. CONCLUSIONS: For this sample of homogeneous anesthesiologists who demonstrated high clinical agreement, it appears that the malpractice system may not be able to function on its own terms in adjudicating malpractice claims. Although there was agreement among respondent anesthesiologists, these assessments were in direct opposition to actual verdicts, a significant percentage of cases resulted in disagreements as to the appropriate standard of care, and anesthesiologists could not successfully predict jury verdicts. The malpractice system appears to be operating far from its theoretical ideal if these results could be applied more generally. Thus, in practice, the legal system, which is to provide an optimal level of injury deterrence, may be a poor method to limit patient injury, improve patient safety, and provide compensation to negligently injured patients in the health delivery system.

Error in medicine: legal impediments to U.S. reform.

Error in medicine is common and can lead to significant patient injury. Although successful systematic efforts to reduce human error have been applied in other complex systems, the field of medicine has just begun to make a broad-based effort in this regard. However, both research in and implementation of patient safety measures may not occur without considering important legal issues that may impede these health policy efforts. Tort and contract law may interact with the vagaries of managed care to limit participation in these error reduction efforts by health care providers as well as by managed care organizations. Thus, for patient safety research to be successful, all members of the health care enterprise must participate in a coordinated effort to identify and establish effective practices that may reduce human error in medicine. But beyond this understanding, it is imperative that legal impediments be recognized and addressed before the goal of a continuously improving, increasingly safe health care system can become a reality.

Blood, bone, and dura: anesthesia responsibility and pediatric neurosurgery.

In conclusion, providing anesthesia for a small child undergoing craniofacial reconstructive surgery is an enormous challenge. Even with the most experienced pediatric anesthesiologist and pediatric surgeons, problems can develop suddenly and lead, as they did in this case, to serious morbidity and even death. It is difficult to determine whether the anesthesiologists' "success" in this case in warding off a malpractice verdict was due to their lawyer's ability to convince the court they delivered a level of "care ordinarily supplied by physicians in their specialty," or, rather, due to the fact that defense experts were more convincing than those of the plaintiffs. Regardless, I do not think there were any "winners" in this situation.