I magine a patient returning a month after uncomplicated cataract surgery. She says that her distance vision isn’t as good as expected, and her refraction is +2.00 diopters. You look back at the operative note and are surprised to find out that you put the intraocular lens (IOL) for the right eye into the left eye—what should you say?
Over the past 15 years, both providers and the public have begun to recognize the impact of medical error. Transparency, including the disclosure of errors, is now considered a critical feature of quality healthcare. However, there has been little discussion of error disclosure to patients in ophthalmology. Moreover, certain aspects of ophthalmology pose special challenges worth considering, such as the frequency of interaction with nonphysician providers (optometrists) and the high percentage of small private practices without hospital-based disclosure resources.
We hope that an introduction to these issues stimulates ophthalmologists to consider what error disclosure means for them and to get training on how to have these conversations. Additionally, we encourage our professional societies to provide more resources and further guidance.
Background on Error Disclosure
The publication of the landmark study To Err is Human focused attention on the extent of medical error, defined as “failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim.” Open communication around errors is critical to meet patients’ and families’ needs and to ensure learning and improvement. Physicians generally support error disclosure but have concerns about it and may struggle to implement it. Multiple factors likely contribute, including conservative advice from attorneys and discomfort with how to have an error disclosure conversation. Fear of being sued is a major concern, with 20% of physicians saying they had failed to disclose a mistake for this reason.
We should point out not only the increased pressure for physicians to disclose errors but also the potential benefits. These include an improved relationship with a patient wondering why there has been a poor outcome, better understanding of why errors occur, and improvement in quality of care. There also may be personal benefits for the ophthalmologist, including less guilt and emotional distress.
There is now greater empiric support for error disclosure, as published evidence from communication-and-resolution programs has demonstrated a significant decrease in claims, lawsuits, length of dispute, and costs. Additionally, multiple standard-setters have officially endorsed disclosure, including the Joint Commission, American Medical Association, American College of Surgeons, and National Quality Forum. Malpractice insurers, including the Ophthalmic Mutual Insurance Company, have done so as well.
Meeting the Challenge in Ophthalmology
We would like to point out a few issues in error disclosure that may be unique to ophthalmologists and suggest ways to start addressing them. As a specialty, we should think about disclosure on our terms because the push for greater error disclosure is certain to continue.
First, the working relationship with optometrists presents a challenge when ophthalmologists take over the care of a patient who has been harmed by an optometrist’s error, and vice versa. Lack of the full clinical picture, fear of offending the other provider (possibly a referral source), and inter-professional cultural differences may create tension and awkwardness. We recommend talking to the optometrist first to learn more about what happened and to try to reach consensus on how to achieve open, honest error disclosure. If conflict arises, the respective practice heads may need to become involved. However, we believe that the key principle and most important duty to uphold is our responsibility to be truthful with our patients.
Optometrists also need training and support for these disclosure skills, making this an area of potential cooperation and communication between our professions to deliver better patient care.
Second, although ophthalmology errors rarely cause death or life-threatening morbidity, we chose ophthalmology because vision is so important to our patients and their quality of life. With refractive surgery, “premium” IOLs, and cosmetic oculoplastic procedures, patient expectations and monetary involvement are high. In situations when patients have made a significant out-of-pocket expenditure, financial restitution may be a relatively more important part of the disclosure process.
Third, most existing programs to improve disclosure take place within large organizations. There are fewer guidelines for error disclosure in smaller private practices, the typical setting for ophthalmology. Because of this, other ophthalmology institutions should step in to fill the gap in training and support, especially the need for “just in time” training for those preparing to have an error disclosure conversation. Many malpractice providers are able to help with this as well.
Finally, ophthalmologists and their patients occasionally have a relationship of very short duration, similar to the challenges of anesthesiologists or emergency room doctors. In some cases, ophthalmologists elect to perform surgery on patients they have met for the first time on the day of surgery and may not plan on seeing these patients again postoperatively. This practice should not be routine but is occasionally employed by some refractive and cataract surgeons.
If an error occurs in this type of situation, having preexisting training in communication and error disclosure skills would be invaluable. Collaboration with the referring ophthalmologist or optometrist is also critical because of the greater depth and duration of their relationship with the patient.
Moving Forward
Thanks to a growing medical literature, we have resources available to provide guidance for addressing the wrong IOL hypothetical from the introduction. Patients strongly prefer full disclosure with use of the word “error” or “mistake” and the doctor’s taking responsibility. With risk management’s guidance, the provider could offer restitution such as providing glasses, laser vision correction, or IOL exchange and assure the patient that steps are being taken to decrease future errors.
Like most surgical subspecialties, ophthalmology has not adopted specific policies endorsing disclosure. The American Academy of Ophthalmology’s Code of Ethics A-4 states that “Open communication with the patient is essential,” but greater specificity and guidance about error disclosure from the Academy and other ophthalmology societies would be helpful. Additionally, we should begin to address the unique issues in disclosing errors to ophthalmology patients as a specialty.
Physicians should seek out training, understanding that actually having an error disclosure conversation is a fairly rare event. However, communications education will likely improve doctor-patient interactions and patient-centeredness of conversations in everyday clinical practice.
We believe that an introduction to error disclosure should be part of the medical school curriculum but is particularly important for residents. The Accreditation Council for Graduate Medical Education and Association of University Professors of Ophthalmology should provide more resources for ophthalmologists-in-training. Three of the core competencies on which residency programs are evaluated include interpersonal skills and communication, professionalism, and systems-based practice. Disclosure training can provide valuable exposure to these competencies. Furthermore, it is important to demonstrate to residents that when errors happen, they should be dealt with in a patient-centered, ethical manner. This fosters a culture of honesty and transparency that will ensure that our newest members incorporate our specialty’s commitment to professionalism and the highest quality of care.
Ophthalmic societies should support disclosure by providing resources that non-hospital-based ophthalmologists may lack. We also ask our societies to support efforts to protect error disclosure from use in litigation to promote open, honest conversations.
The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and indicate no financial disclosures. There was no direct funding or support, although the University of Washington Department of Ophthalmology receives an unrestricted grant from Research to Prevent Blindness, New York, New York. Contributions of authors: preparation, review, and approval of manuscript (B.L., T.G.).
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