CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
Paul A. Raslavicus, MD
October 2002—It is an axiom that painful transition is a prerequisite for meaningful change. This is true of organizational change as well as of life passages. It is also true of social and economic movements. Changes occurring now in the culture of our health care system suggest that the issue of medical liability is in this type of transition.
We have heard much about patient safety, sentinel events, and systems error, which are the themes of two monographs published by the Institute of Medicine’s Committee on Quality of Health Care in America. Both documents, titled To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, propose sweeping, systemic changes and have sent ripples across the profession.
To Err Is Human, the major goal of which was to end what it termed a “cycle of inaction” about patient safety and medical error, generated far more publicity than the second, though the latter covers more ground. Crossing the Quality Chasm calls for broad-based health systems improvement in six areas: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
To Err Is Human put patient safety and medical error on the Sunday morning talk shows, but it is the new Joint Commission on Accreditation of Healthcare Organizations standard requiring that patients and families be “informed about outcomes of care, including unanticipated outcomes,” that brings the story home. We in the practice of pathology serve patients, and when failures occur in the provision of our services, we are all affected by this standard. This, of course, applies to problems of transcription, misidentification, or misinterpretation in the clinical laboratory as well as matters of misinterpretation when dealing with tissues or cells.
Many of us have been raised in the tradition of paternalism, where the patient is told only what she or he needs to know. We tend to look in horror at this new standard, which seems to be, at best, an invitation to higher levels of liability risk. Yet there is a positive side. For many of us, this new policy is in concert with our personal ethic of being truthful with those who entrust us with their care. This standard, too, without question, is consistent with the patient empowerment movement that is sweeping the country. Appropriate disclosure also is important to preserving patient relationships that could otherwise disintegrate, improving outcomes for others by prompting systems improvements, and helping patients form more realistic expectations of a system that, as we all know, is not infallible.
Preliminary evidence suggests that voluntary disclosure does not lead to an increase in liability lawsuits. When settlement does take place, the monetary payments are often lower. This is so in part because prompt and considerate disclosure defuses anger, and in part because lawyer fees and hyperbole are minimized.