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Hospitals and health systems have been launching campaigns to get patients and families to speak up when they've experienced medical harms such as a misdiagnosis. Great idea, right? Wrong, says Thomas Gallagher, MD.

"I think that's going about it completely the wrong way," said Gallagher, executive director of the Collaborative for Accountability and Improvement at the University of Washington in Seattle.

"The organization has a responsibility for creating an environment where you as a patient feel like it's safe to raise your hand if something has gone wrong ... We want to hear your concerns; we want to partner with you for solutions," Gallagher said Thursday at a hosted by the Iowa Healthcare Collaborative.

Why don't patients speak up when something goes wrong? A found that among patients who were harmed and chose not to report it, the reasons included wanting to focus on their own health, put the event behind them, or focus on the future (28%); believing that reporting the event would not do any good (12%); believing the injury or error was fixed or not significant (6%); uncertainty about who was responsible for the event (5%); and concerns about the impact on the clinician involved (3%).

Other reasons patients often give for not reporting are not wanting to be a "complainer" and not wanting to hurt anyone's feelings, Gallagher said.

He noted that clinicians and researchers who were interested in misdiagnosis were very excited in 1999 when the Institute of Medicine -- now the National Academy of Medicine -- published a landmark report on medical errors and what could be done to prevent them. "There was so much excitement and enthusiasm ... that we were going to make a transformation in the quality and safety of healthcare," Gallagher said.

"There has been progress -- there's no doubt about that -- but it's not been nearly as much as anyone would have liked," he said. "I think the most important reason why that is, is that when something has not gone well, we're not always open. We're not transparent; we're not always learning."

Transparency, however, is not an end in and of itself, he continued. "We really should be thinking about transparency as an instrumental good that leads to a variety of other benefits ... Openness helps us identify problems, both those that have happened and that are potential problems; it allows us to analyze the problem and develop plans for preventing recurrences. It promotes informed choice about how we should respond."

On the other hand, "when you ask patients about openness, and what the benefits of openness are, they don't talk a lot about informed decision-making and informed choices," Gallagher added. Instead, "they talk about respect and autonomy: 'Something has gone wrong. I expect -- just as respectful treatment of me as a person -- that you'll let me know about what happened.'"

So what can clinicians personally do to make it easier next time they're involved in a situation where this type of openness is called for?

"Reach out for help and guidance; if I had one suggestion, that's the one," he said. "We tend to make bad decisions when we do things in isolation ... We want you to feel comfortable stepping forward when something has not gone well."

Unfortunately, "everyone has the instinct to want to keep uncomfortable information to ourselves -- If I just keep my head down, maybe this will all blow over," said Gallagher. "This is even more complicated because there are mixed messages that we get from the organization: 'Of course we want you to be open and tell the patient, but don't say THAT.' It's going to make the inclination to keep information to yourself even stronger."

Clinicians have been hearing from risk managers and attorneys for decades that "when something goes wrong, it's best not to say anything," Gallagher said. The issue also is complicated because although there are some cases where a diagnostic error clearly led to a harm that the patient experienced, "much more commonly, we're dealing with gray areas -- the diagnostic process has not gone perfectly but it's unclear whether there was a delay, unclear whether there was an error. It's even less clear, did that delay cause harm to the patient, and if so, how severe was that harm?

"And all the while, these cases are playing out with multiple stakeholders -- oftentimes multiple providers, sometimes multiple institutions, multiple insurers -- and that makes being transparent event more difficult," he continued.

Communications between colleagues when an error occurs also can be tricky. "There's a lot of concern about, 'Well, how is the colleague going to react'" if I speak to him or her about the error, said Gallagher. "'What does it mean to be a good colleague here? I'm not supposed to be tattling' -- we've learned that from when we were little."

For clinicians who want to make their own institutions a little more transparent, "there are lots of folks nationally able to help with that," he said. One thing that may make those in the C-suite sit up and pay attention are the financial implications of being transparent: Gallagher cited an explaining that the hardening medical malpractice liability market makes implementing (CRPs) at healthcare institutions more important than ever.

"Generally speaking, it's a misplaced fear of punitive consequences that -- even at the level of the senior leaders -- holds them back," he said. "When they recognize that there are ways to enact CRPs in a comprehensive way that leads to a whole range of benefits, they start to see why this is a broader investment in culture and start to get more interested and involved."

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