Hospitals rarely tell all

from Portland Tribune

Legacy death highlights reluctance to admit medical mistakes

READ - Report on the death of Glenn Shipman - Statement of Deficiencies and Plan of Correction, created by HCLC on 10/3/07 (PDF 1.8 MB)

When Kathy Shipman was shown an Oregon Department of Human Services report that said Glenn Shipman, her brother, had died after being restrained face down on the floor by the staff at Legacy Emanuel Hospital & Health Center, she said it was a blessing to finally know the truth.

But Shipman, who saw the DHS report last Friday, said she and her family would have liked to know the truth much earlier — and wished Legacy would have been willing to tell them.

Glenn Shipman died Aug. 26.

Kathy Shipman said that from the day her brother died until an Oct. 23 meeting with hospital officials that the family requested, the hospital had no contact with Shipman’s family except for a call from a nurse who wanted to send flowers.

At that Oct. 23 meeting, both Kathy Shipman and Glenn’s mother, Elaine Shipman, said hospital officials never told them that Glenn died from asphyxiation, as stated in the state medical examiner’s death certificate. They said hospital officials told them Glenn had been restrained and that he had died of cardiac arrest.

“They did say they were sorry for our loss,” Kathy Shipman said.

But, she said, hospital officials did not acknowledge the death was related to their restraint of Shipman — which is what a DHS official believes.

“They pointed to Glenn’s weight (over 400 pounds) and said he had apnea,” she said. “It feels like Glenn is no longer the victim here but he’s the perpetrator. That’s the impression I got out of it.”

Hospital officials said they could not comment on the case while it is under investigation.

Asked for the hospital’s policy on disclosure of accidents or mistakes to patients or their families, a Legacy spokeswoman wrote in an e-mail statement that the hospital had “clearly defined protocols” it followed when unanticipated events occurred.

Asked through an e-mail for more details on those protocols, Legacy officials did not respond.

Legacy’s response to the unexpected death of Glenn Shipman is hardly unusual.

Despite a national movement to encourage hospitals and doctors to tell patients what they know after unexpected events, most, fearing lawsuits, reveal little, according to experts in the field of medical disclosure.

Lawrence Wobbrock, a Portland malpractice attorney for 31 years, isn’t convinced that there’s been all that much change in hospitals and doctors willing to admit their mistakes.

“In general (hospitals in Portland) rarely disclose what happens,” Wobbrock said.

The Oregon Legislature approved a law in 2003 that requires hospitals to disclose serious events in writing to patients, but the law doesn’t say what or how much they have to disclose.

The statute also says that statements made by a physician in disclosure to a patient cannot be used against the doctor should a case be taken to court.

Wobbrock says the law is weak.

“I’m finding that occasionally they’ll apologize, but they know it is not admissible,” Wobbrock said. “I have seen no change in hospitals informing patients when a bad thing happens, that it’s someone’s fault.”

Nationally, a 2003 study by University of Washington School of Medicine assistant professor Thomas Gallagher discovered that only one in three doctors who as patients were victims of unexpected events were told about the problem by their own doctors.

“It’s not what we’d like it to be,” Gallagher said of physicians’ willingness to disclose.

Move toward disclosure

Gallagher and other national experts say that hospitals could and should tell patients everything they know, and more hospitals are starting to do just that.

“This is not about preventing lawsuits,” said Jim Conway, senior vice president for the nonprofit Institute for Healthcare Improvement in Cambridge, Mass. “People will do what they do. This is about the organization honoring their moral and ethical responsibility to disclose.”

Kathryn Wire, a St. Louis-based attorney and risk management consultant to hospitals, said she advises hospitals that telling harmed patients or their families what they know is not only right for the patients, but also good business for the hospitals.

A number of studies in recent years, Wire said, have reported that when hospitals and doctors are more open and honest with patients who are victims of “unexpected events,” the hospitals don’t suffer financially because potential lawsuits get resolved more quickly.

Wire said that, after reading the Portland Tribune’s Tuesday stories about the Glenn Shipman case, she would have advised Legacy Emanuel to disclose details to the family before the release of the DHS report.

That report cited the hospital for failure to meet federal standards for patient safety.

The DHS report said that the hospital failed to adequately monitor Shipman’s condition while he was being restrained.

The DHS report also cited the hospital for a locked door that kept a resuscitation team from getting to Shipman, and for a staff worker not knowing how to operate a medication dispenser after Shipman had stopped breathing.

Wire said the hospital could have revealed some of those facts to the family without knowing, or saying, if they contributed to Shipman’s death.

She said family members often just want to hear from the hospital that measures have been taken so that those problems don’t occur with future patients.

Jim Conway agrees, and he has experience in patient disclosure that few hospital administrators can match.

Conway was brought in as executive vice president of the Dana-Farber Cancer Institute in 1995 to deal with what probably was the most highly publicized medical mistake in recent history.

Case brought spotlight

In 1994 Betsy Lehman, a Boston Globe health columnist, was killed by an overdose of chemo-therapy drugs at Dana-Farber, considered one of the country’s pre-eminent cancer hospitals. Lehman’s death made headlines around the country, and focused attention on hospital mistakes.

Dana-Farber, Conway said, fully disclosed to Lehman’s husband all that they knew, and quickly reached a legal settlement with him.

“Our board of trustees said there was no conflict over what happened, so let’s settle with the family and spend the time making sure it never happens again,” Conway said.

Conway said that full disclosure yields patient trust. Every patient that has been harmed by an unexpected event at Dana-Farber and has been provided full disclosure has remained at the hospital as a patient, he said.

Conway said hospitals are beginning to change, slowly.

“This is a cultural change, and you don’t change cultures overnight,” he said. “People have been living in this shame and blame, keep it quiet, don’t disclose (environment) for most of the tradition of health care. It’s like trying to turn a ship around.”

Peter Bernardo, a Salem surgeon who is vice president of the Oregon Medical Association, said telling patients just makes good sense.

“Most patients are not accusatory, and most of the time they’re going to find out about it anyway,” he said. “In this day and age it doesn’t do you any good to lie about it.”