Disclosure and apology after an adverse medical event where errors contributed is not only the right thing to do, it also likely results in lower liability costs. Our numerous columns on the issue are listed below. Disclosure and apology has evolved into “communication-and-resolution” programs. Such programs communicate with patients when adverse events occur, investigate and explain what happened and, where appropriate, apologize and proactively offer compensation.
Our most recent columns on the issue (our October 2017 What's New in the Patient Safety World column “” and January 3, 2017 Patient Safety Tip of the Week “”) discussed not only successes of such programs but also barriers to successful implementation.
A new study further demonstrates the success of communication and resolution programs (CRP). LeCraw and colleagues compared liability outcomes before and after collaborative communication resolution program implementation at a health system in Tennessee (LeCraw 2018). 43% of events with injury from medical error were resolved with apology alone. Compared to pre-implementation levels, there was a decrease in the average number of new claims filed (1.07 to .36), defense costs ($41,950 to $20,623), settlement costs ($19,480 to $14,228), and total liability costs ($61,430 to $34,851) under collaborative communication resolution program, all measured per 1000 hospital admissions.
No medical error occurred in 65% of adverse events. One percent of adverse events when there was no medical error received compensation.
Moreover, the median time interval to resolve a claim decreased from 17 months to 8 months, a reduction of 53%.
The LeCraw paper describes the CRP process in detail:
At an initial meeting patient or family members tell their story and describe the impact of the event. Family members and/or attorneys are welcome at all meetings and the involved physician or other healthcare provider representatives are encouraged to attend. The primary goal of the initial meeting is to listen and learn about the patient’s questions and concerns. Risk Management (RM) staff describes the resolution process and answers any questions about it.
The reported event is then investigated through the hospital’s usual incident investigation processes. A second meeting takes place between one week and one month after the first. Again, involved physicians may be invited to attend the second meeting. RM reviews the discussion from the first meeting and invites the patient to provide any updates. All non-privileged information about the incident is disclosed to the patient. An effort is made to reconcile the patient’s version of events with the one ascertained through the QI investigation. RM staff answers any remaining questions and agrees to investigate further any unanswered questions.
A patient who is satisfied with the results of the investigation may wish to conclude the meeting without making any requests. The study found that in cases where the patient feels that a medical error took place, the most common requests are for an apology, explanation of the adverse outcome, and some change in hospital policy or operations. If the adverse outcome was the result of medical error, the error is acknowledged, and a sincere apology is given, along with a commitment to change hospital policies to prevent or minimize the chances of recurrence. (The hospital is only able to address those elements involving the hospital, unless the physician agrees to participate.) If compensation is requested by the patient for an adverse outcome due to medical error, the patient is asked to give a breakdown of the amount of compensation requested. RM presents this information to the claims committee, which determines their value for the injury and an amount to offer as compensation.
If the investigation determines no medical error occurred, an explanation is made for the adverse outcome and why the hospital believes the standard of care was not breached. Any request for compensation is denied. RM staff continues to answer the patient’s clarifying questions and may offer to participate in mediation if the patient is not satisfied with the explanation. There is also the potential for a patient who disagrees to initiate a formal legal claim.
When a medical error occurred and compensation is requested, a third meeting is proposed no more than 90 days following initial contact with the patient. Any changes to hospital policy or procedures resulting from the incident are explained to the patient/family with an explanation of how the changes are expected to prevent a recurrence. If the patient accepts the offer of compensation and/or the hospital’s efforts to change policy, a settlement document is signed. If the offer is rejected, RM staff may offer to participate in mediation. If all these efforts are unsuccessful, the patient may still pursue a formal legal claim.
The results achieved in this CRP program are very reassuring. Also, since attorneys were involved in 60% of the above events, the success reported should be encouraging to physicians and hospitals alike. Disclosure and sincere apology go a long way to mend fences when adverse events occur and it’s becoming increasingly clear that full “communication-and-resolution programs” are satisfying to hospitals and patients/families and less costly in the long run.
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “ ”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
December 17, 2013 “The Second Victim”
July 14, 2015 “NPSF’s RCA2 Guidelines”
June 2016 “”
August 9, 2016 “More on the Second Victim”
January 3, 2017 “”
October 2017 “”
Other very valuable resources on disclosure and apology:
LeCraw FR, Montanera D, Jackson JP, et al. Changes in liability claims, costs, and resolution times following the introduction of a communication-and-resolution program in Tennessee. Journal of Patient Safety and Risk Management 2018; First Published February 14, 2018; 23(1): 13-18