Hospital Leadership and Legal Transparency Panel

David Mayer, CEO of the Patient Safety Movement Foundation, Mike Durkin, Senior Adviser on Patient Safety Policy and Leadership of Imperial College London, Jack Gentry, Patient Advocate, Allen Kachalia, Senior Vice President of Patient Safety and Quality of Johns Hopkins Medicine, Peter Lachman, CEO of ISQua, and Jon Schochor, Senior Managing Partner of Schochor, Federico & Staton PA, sit down to have a conversation about implementation of the CANDOR system, investigation of clinical errors, the system surrounding protection of physicians after in-hospital errors, and possible solutions to repair the situation for not only the patient and family, but also for the healthcare team involved in the error. Jack Gentry begins by explaining the incredible difference the transparency of the healthcare team involved in his medical error made and how he was able to rebuild his life with this healthcare team thereafter. Many discuss the secrecy surrounding medical errors in the hospital and speak of how many physicians will close the door to the patients and depict the patients as the enemy after they have made a medical error. Instead of caring for the patient after a traumatic experience, the healthcare team becomes cold and quiet. Schochor mentions that the US does not have any independent investigators for medical error. Instead, he notes that a huge problem with transparency in US hospitals is the fact that we do not question who is evaluating the situation after the error has occurred and often, the evaluator works for the hospital itself. The panel also highlights the idea that communication between the patient and the providing team needs to be facilitated to allow for healing on both sides. Furthermore, the patient should feel encouraged to step into an active role in communication of the error. "What do you think happened?" "What do you remember feeling emotionally?" These are questions that will encourage patient engagement and ensure that a comprehensive view of the error is being captured.