The retired engineer could barely comprehend what the doctors were saying. They were telling him that his wife of 30 years had unexpectedly died while she was intubated and being prepped for a tracheostomy. Before the procedure even began, she had started gasping for breath and her heart failed. The doctors were trying to figure out what happened, they said.
The next five hours were nightmarish. Police were called in because tampering was suspected in hospital machinery; medical staffers were vague, even evasive. The woman’s husband saw people in suits rushing by or talking to administrators, and remembers thinking, “Gee, it would be nice if they would come by and talk to us.”
It took a lawsuit and experienced attorneys to determine that his wife’s death was the result of a medical error: a mechanical blockage in the intubation apparatus. While the engineer received a settlement for medical error in 2018, a year after his wife’s death, he remains deeply frustrated by the nondisclosure agreement he had to sign, and the lack of information he received from the hospital.The nondisclosure agreement prevents him from openly sharing details about this case. The hospital administrators have assured him that they changed procedures and vendors to prevent this error from happening again, “but what about the other 6,000 hospitals in the country?” he thought. Shouldn’t they know about a possible mechanical issue? How would other hospitals prevent this tragedy from happening to another family?
So the man decided that the settlement fund would be used to create something positive out of a horrible experience. He chose to support the Ariadne Labs Communication, Apology and Resolution (CARe) program.
When patients are harmed by a medical error, some healthcare organizations employ a communication and resolution program to provide clear information and emotional support to patients or their families. Such programs also determine what went wrong and facilitate internal learning so the mistake can be prevented. Apologies and, if appropriate, compensation are offered. However, the effectiveness of such programs are often undercut by inconsistent or partial implementation. Ariadne’s CARe project aims to scale Communication, Apology and Resolution approaches to every hospital in the United States so it becomes the standardized response in the event of a medical error.
In collaboration with the University of Washington’s Collaborative for Accountability and Improvement (CAI), Ariadne Labs is advancing this work by developing and testing standardized measures to help organizations gauge and ultimately improve the effectiveness and reliability of their communication and resolution programs.
With generous assistance from the donor, Ariadne researchers will design, test, and spread a scalable, patient-centered CARe tool that health systems can use for effective, transparent, and compassionate response to medical errors.
“How do you make it easy to do the right thing?” says Dr. Evan Benjamin, Ariadne Labs chief medical officer and a leader in the movement to spread communication and conflict resolution programs. “Often when we see a problem, someone has solved it. But it hasn’t been scaled and spread. We want to make solutions universal.”
The need for better responses to medical errors is huge, notes Benjamin. According to 2013 Medicare data:
- 13.5% of hospitalized beneficiaries experience an adverse event
- 1.5% experienced harm that contributed to death
- 44% of adverse events were preventable
Moreover, failed or inadequate responses to adverse events compound the suffering of patients and family and heighten the distress of clinicians. A study released earlier this year by the Betsy Lehman Center for Patient Safety found that medical errors in Massachusetts for one year topped 61,982 and led to $617 million in excess costs. Yet only 19 percent of Massachusetts patients who experienced an error received an apology from health providers. Overall, poor responses leads to a reduction of the public trust in health care. Many patients feel they are never told the truth, Benjamin says.
However, the research demonstrates that doing the right thing can significantly ease patient and family suffering. And, it turns out, doing the right thing for patients is good for health systems and providers too. Transparent responses to adverse events, including apologies, do not increase the likelihood of litigation. More importantly, identified problems may be addressed so that another patient won’t be injured by the same error.
“We know what we should do, but in practice we don’t do it. There’s a know-do gap,” says Benjamin. “We need to close that know-do gap.”
The donor, for example, says he never received an apology from the hospital – and he still wants one. Instead, he learned that hospital staff was instructed to avoid him.
In recent years, the medical establishment has begun to recognize the value of greater transparency. “It’s almost a social movement,” Benjamin says. “We have to give people the tools to do it. The aim will be to foster a culture of learning, not blame.”
To develop these tools, the Ariadne CARe team is analyzing data from the Stanford University Medical Indemnity and Trust, the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI), the University of Illinois Chicago, the University of Michigan and other institutions.
For example, a timeline developed by MACRMI specifies precise actions to take 24 to 48 hours after an event, 2 to 3 weeks later, 1 to 3 months later and even 3 to 6 months later. Another innovation utilizes a communications and disclosure checklist, and another employs a flow-chart or map to coordinate responses. The Stanford University Medical Indemnity and Trust found that CRPs reduced the frequency of lawsuits by 50 percent; the University of Illinois Chicago found median times to resolutions dropped from 55 to 12 months; and MACRMI found that costs to hospitals was reduced.
Additionally, Ariadne’s CARe team in collaboration with the CAI is developing a set of metrics to:
- Create benchmarks for success and accountability.
- Guide comprehensive, systematic communication and response program implementation
- Measure ongoing reporting, transparent learning, and communication
The final stage will be to “spread” the successfully tested tool among health-care institutions.
The donor said he was impressed with the Ariadne approach. “I started out thinking we could help people who were hurt by medical errors,” he says. “Now I think about how to reduce the number of errors.”