The theme of this blog is medical errors. But the legislation my family has proposed is titled The Kansas Apology and Disclosure of Unanticipated Medical Outcomes and Medical Errors Act. I would like to briefly explain the reasoning behind this.
The main purpose of our proposed legislation is to ensure that patients (and their families) are informed about harmful errors, and informed about them in a reasonably expedient manner. But errors are not always immediately obvious. For example, a healthcare provider may know that the way a patients body reacted to a procedure was not normal, but at that moment it may not be clear if an error was made. But if the patient is experiencing this unanticipated outcome that information should not be kept secret. The patient (and/or family, as appropriate) should be informed of what is known, and the healthcare team should initiate an investigation and keep the patient/family updated with any new information. Therefore, by requiring that unanticipated outcomes as well as errors are made known to the patient/family, it removes the need to make an immediate judgment about whether an error was made.
There is another term, adverse event, that has a meaning quite similar to unanticipated outcome. We choose to use unanticipated outcome because the Joint Commission (an organization which accredits many hospitals) has required disclosure of unanticipated outcomes since 2001.
These are the definitions in our proposed legislation:
- Medical error means the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. This includes errors of commission (errors that occur as the result of an action taken) and errors of omission (errors that occur as a result of an action not taken). (The source of this definition is the report To Err is Human: Building a Safer Health System, Committee on Quality of Health Care in America, Institute of Medicine, 2000)
- Unanticipated outcome means any adverse event, sentinel event or unintended or unexpected outcome or injury, whether or not resulting from an intentional act, that is not due to an underlying medical condition of the patient. (This wording is based on the definitions from several sources for unanticipated outcome and adverse event.)