The approach to communicating with patients about other clinicians' errors should be determined through research into how this challenge arises; the preferences of patients, clinicians, and institutions regarding handling such situations; and outcomes data regarding disclosure strategies. The following principles should be refined as data and experience accumulate.

Patients and Families Come First

Although anxieties about damaging collegial relationships loom large in situations of potential error involving other clinicians, a patient's right to honest information shared with compassion about what happened to him or her is paramount. Simply put, when disclosure is ethically required, the fact that it is difficult must not stand in the way. Patients and families should not bear the burden of digging for information about problems in their care.

It must also be acknowledged that many families will need financial help after a serious error and will have a hard time accessing compensation without information about what happened. Clinicians rightly perceive the current medical liability system as flawed and understandably worry that they may not be treated fairly should a patient file a claim.29 But these concerns do not obviate clinicians' duty to be truthful with patients; as professionals, clinicians are expected to put the patient's needs above their own.

Explore, Do Not Ignore

Before initiating a disclosure conversation about a colleague's possible error, a clinician's first obligation is to obtain the facts. Patients' interests are not served by communicating inaccurate or speculative information, and colleagues deserve the chance to correct mistaken assumptions and join disclosure conversations with their patients.

A strengthened commitment by clinicians to “explore, don't ignore” potential errors is needed, and it will require that clinicians improve their ability to discuss quality issues with one another. This commitment is fundamental to the self-regulation that lies at the heart of medical professionalism. Professional self-regulation should not be conceived of as something individual clinicians do, but rather as something the profession does collectively — and can only do by sharing and acting on information together.30

Ideally, we envision the process starting with a colleague-to-colleague conversation about what happened. Interacting directly with the involved colleague is part of our professional responsibility. It is how we would hope a colleague would treat us, and it can promote learning. For a productive discussion to occur, it is essential to frame the conversation in ways that minimize a colleague's defensiveness. A shift to a more proactive approach to discussing colleagues' potential errors should be balanced by a willingness not to rush to judgment. Explorations should be undertaken with the assumption that persons who were not directly involved in the care have incomplete information, and the discussions should be approached with curiosity rather than accusations.31

The goal of the discussion with the involved colleague is to establish what happened and, if needed, how to communicate with the patient. The path forward will depend on the outcome of the peer-to-peer conversation. The colleagues may agree there was no harmful error, and the process can stop. If they agree there was a harmful error, they can discuss what needs to be reported through institutional channels and disclosed to the patient. The colleagues may also disagree about what happened or whether disclosure is warranted. When these or other challenges described below occur, it is appropriate to turn to the institution or health care organization for assistance, if possible.

Table 1. Table 1. Disclosing Harmful Errors in Common Situations Involving Other Clinicians.

The challenge of disclosing another providers' error can arise in various situations. Table 1 outlines several common situations and proposes a disclosure strategy for each. The recommendations place a priority on patients receiving needed information about harmful errors through skillfully executed disclosure conversations. The recommendations regarding who is responsible for the disclosure were derived by considering who has the strongest ongoing relationship with the patient, the best understanding of what happened and its implication for the patient, responsibility for the patient's current care, and the most experience with disclosure in complex situations (such as those involving multiple institutions). The proposed strategies also recognize the advantages of the disclosure being conducted jointly by the involved clinicians. This avoids sending the patient mixed messages, ensures that key information is communicated clearly (rather than merely hinting at the error, so that the patient is left responsible for “connecting the dots”), and demonstrates shared responsibility for transparency.

Institutions Should Lead

Although colleague-to-colleague discussions should be the starting point for exploring potential errors, institutions are ultimately responsible for ensuring that high-quality disclosure conversations occur with patients, regardless of which clinicians were involved in the event.4 Institutional leadership is especially important when the patient had considerable harm, multiple clinicians or other institutions were involved, communication among colleagues has broken down, the colleagues disagree about what happened or whether disclosure is warranted, and concerns are raised about conflict of interest (e.g., the colleague in question is a financial competitor). Institutions that play a prominent role in such situations ensure that a careful review of the event is performed and that clinicians have not assumed that disclosure is someone else's responsibility and left the patient in the dark.

Institutions should support conversations between clinicians as they seek to explore potential errors. Many institutions are developing just-in-time disclosure coaching programs that could help clinicians conduct respectful conversations with colleagues about potential errors.15 A disclosure coach can facilitate peer-to-peer discussions, enabling each party to share his or her perspectives with less defensiveness. Role modeling by senior colleagues is also essential to encourage meaningful discussions among clinicians.

Existing formal venues for discussing concerns about quality such as morbidity-and-mortality conferences and peer-review committees could also address questions about potential errors involving colleagues. In addition, less formal mechanisms such as a “curbside consult” with a quality expert or risk manager could help clinicians access the institution's event analysis expertise (under the appropriate peer-review and quality-improvement privileges) while minimizing clinicians' fear of a punitive review process. Institutions could enhance their preparation for handling errors involving colleagues by using the atrial fibrillation case to simulate how existing quality, safety, and risk structures would help clinicians respond. Institutions could also use the case to identify opportunities for improvement. Such organizational preparation is preferable to confronting these crises only when they arise.

Institutions should also strengthen “just cultures,” which are “atmospheres of trust in which people are encouraged, even rewarded, for providing essential safety-related information — but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior.”32-34 Just cultures encourage clinicians to report adverse events and help address hierarchy issues involving nurses and trainees that can obstruct the free flow of information to the patient.

Similar resources will be needed for clinicians who do not have a strong institutional connection. These clinicians' liability insurer or insurers could provide similar support and, indeed, many insurers have expanded their disclosure coaching resources. Support could also be provided by local medical societies and national professional organizations. Patient-safety organizations could fill this role over time, have the advantage of strong statutory protections for the confidentiality of information reported to them, and can help bridge the gap in cases that involve multiple institutions.35