Back in 1987, the Lexington, Kentucky VA Hospital adopted a policy of disclosing errors. I found a documentary online, called The Quality Gap: Medicine’s Secret Killer, that was released in 2000. It has interviews with two key people who developed the disclosure policy, Ginny Hamm (VA attorney) and Dr. Steve Kraman (Chief of Staff).
The documentary begins with the story of Claudie Holbrook, who was taking daily injections of a blood thinner, called heparin, to prevent blood clots. The VA refilled his prescription at a dose that was ten times too low, and he later died of a blood clot. The VA acknowledged the error to his family, in accordance with their policy.
This openness with patients and families contrasts strongly with the hospital next door, the Chandler Medical Center at the University of Kentucky. Dr. James Holsinger, an administrator at the Chandler Medical Center, explains they cannot be honest with patients about errors because patients would seek out lawyers.
Here are a few quotes…
Describing the reaction of people in the medical community to their disclosure policy:
Ms. Hamm (8:16)
People thought you were crazy if you suggested an admission of liability.
Dr. Kraman (8:24)
They thought we were out of our minds doing this. This is not the way you…not the way you handle financial risks to an institution.
Explaining how the medical community traditionally deals with errors:
Dr. Kraman (8:46)
I liken it to hit and run. Because what you are doing, you make a mistake and somebody’s hurt. They don’t say anything, no one else sees, you just go on and maybe put a little money aside, in case they file a suit.
Their perspective on injured patients seeking lawyers:
Ms. Hamm (10:50)
The first person I want to hear from is a malpractice lawyer. A good malpractice lawyer understands the law. They understand the concept of damages. And you can bargain with them and deal with them instead of worrying about breaking down a very carefully put together relationship, a fragile relationship, like you have with the family.
Why they developed the disclosure policy:
Ms. Hamm (11:29)
It’s not about me. It’s not about us. It’s about Mr. Holbrook. It’s about Mrs. Holbrook and the daughters. It just can’t be about us anymore once the mistake is made.
Ms. Hamm (13:32)
You have to be brave enough to believe that your morals, your ethics, and your experience are going to serve you well. You’ve got to take a risk. That’s why we call it risk management.
Dr. Kraman (14:28)
Most patients can understand that doctors make mistakes. What they can’t understand is lying to cover them up.
The documentary continues with two other stories: New York’s decision to publicly report death rates after open-heart surgery and how two groups of physicians improved care by standardizing treatments for their patients.
This is a powerful and inspiring video, but these stories are from the 1980s and 1990s. The leadership of Ms. Hamm and Dr. Kraman was extraordinary for the time, but this is 2013. Leadership of this type should now be considered ordinary. So why didn’t my family encounter anything like this in Kansas?