Medical errors and the movement toward transparency

Listen to the discussion

(MP3, 10MB, 42 minutes)

The Chicago chapter of AHCJ recently hosted David Mayer, M.D., co-producer of the award-winning film, "The Faces of Medical Error … From Tears to Transparency: The Story of Lewis Blackman," and a leader on transparency in health care. Mayer is associate dean for the University of Illinois at Chicago College of Medicine, co-executive director for UIC's Institute for Patient Safety Excellence and a practicing anesthesiologist.

Mayer has been active in patient safety and health care risk reduction strategies throughout his career and, with Tim McDonald, M.D., has co-founded Transparent Health, an organization dedicated to the prevention of patient harm. Most recently, McDonald and Mayer were awarded a $3 million federal grant to implement and evaluate patient safety efforts on a larger scale.

David Mayer, M.D.

Mayer described changing the culture of "deny and defend" in hospitals to a culture free of "shame and blame," in which health care providers acknowledge mistakes that are made. In such efforts, providers are encouraged to learn from mistakes and they explain the errors that do harm to patients and their families.

"Patients do not sue out of greed, they sue out of anger," Mayer says. They have found that rather than going to court, patients and their families want a truthful description of what happened, they want their questions answered, they want an apology and they want to know there will be a remedy."We've found many times the remedy is just don't bill them."

Mayer showed part of the film, which tells the story of a boy who eventually died as a result of medical errors despite his mother’s persistent requests for medical help. Mayer then took questions from attendees about patient-safety initiatives and what they have learned. Among the topics he discussed:

What hospital lawyers think about such transparency
How doctors learn to talk about errors and admit to making them
Patient-activated rapid response teams that react to patient's family members' concerns
How hospitals taking part in this program are insured
How hospitals handle "near misses"
What it takes to get residents to report unsafe conditions, adverse events and near misses
Whether such a system has this done anything to weed out incompetent or negligent providers
Why, all these years after The Joint Commission came up with sentinel events and other measures to reduce errors, we are still talking about culture change
What metrics Mason and others will use to evaluate success