View as “PDF version”
Patient Safety Tip
of the Week
March 9, 2021
Update: Disclosure and
Apology: How to Do It
We’ve come a long
way in our responses to medical errors. It’s now
widely accepted that disclosure and sincere apology to patients and their families
or significant others are the right thing to do following errors that lead to
adverse patient outcomes (and even those that do not lead to patient harm).
Ever since we set up
our first guidelines on responding to serious incidents in the early 1990’s
(see our July 24, 2007 Patient Safety Tip of the Week “Serious
Incident Response Checklist”) we have always included a section in our “Serious Event Response Checklist” for notifying the patient and/or family
that errors had occurred in their care. Yet we continue to see hospitals and
physicians struggle with “how do we do it?” even once they have bought into the
basic concept.
We did discuss how to undertake such
communication back in our June 22, 2010 Patient Safety Tip of the Week “Disclosure
and Apology: How to Do It” and
multiple other columns listed at the end of today’s column.
An excellent recent review (Kaldjian 2020)
discusses all the elements necessary to make such conversations productive.
These involve respect, compassion, and commitment by providing information,
acknowledging harm, and maintaining trust through a process of dialogue that
involves multiple conversations.
Kaldjian begins
with a succinct summary: “Communication about medical errors with patients and
families demonstrates respect, compassion, and commitment to patients and
families after an error has occurred by providing information, acknowledging
harm, and maintaining trust through a process of dialogue that involves
multiple conversations.”
It is especially important that any apology
is sincere and honest. It must be delivered with empathy and respect.
You also want to let them know about
continued care for the patient (assuming it was not a fatal error), what harm
the error may have caused, and how what will be done about that harm.
Kaldjian outlines
the key elements of a medical error discussion:
- Prepare
for the discussion
- Provide
information
- Encourage
dialogue
- Appreciate
suffering
- Express
regret
- Accept
responsibility
- Explain
the care plan
- Outline
the next steps
- Promise
to improve
We note one important consideration missing
from the otherwise excellent Kaldjian review: the
venue for the discussion. You need to make the patient/family comfortable
and encourage them to engage in dialogue. The worst mistake we see is holding
the discussion in the board room of a hospital with multiple hospital figures dressed
in white coats or suits and ties sitting across from them. That is an
intimidating environment and almost immediately puts the family in a defensive
posture. We recommend the discussion take place in a small room with
comfortable seating and no table or other furniture in the way.
We recommend you keep
the number of hospital personnel to a minimum. That should include the
clinician providing the disclosure. That is usually the attending physician,
though in some cases it may be someone else, such as a medical director or
department head. It’s good to have one other “hospital” person in
the room. That might be a risk manager or the person who will lead the RCA
sessions, though it could also be a patient advocate if your organization has
such a position. Or it might be a nurse or other healthcare worker who has
developed a good rapport with the family. Patients and families often look to
that other person for support and clarification. That person also may be more
experienced in these discussions and can keep the clinician focused on the key
elements of the discussion. And the patient or family may come to that person
with questions they are afraid to ask the physician.
One other issue not
discussed in the Kaldjian review is the question “When should you
notify the patient and family?”. In our June 22, 2010 Patient Safety Tip of
the Week “Disclosure and Apology: How to Do It” we recommended that you let the
patient/family know about the incident as soon as possible. Obviously,
you need to know enough about the event or incident to be able to discuss it
with them. But sometimes you may not have all the details early on (for
example, you may not yet have done your root cause analysis). It is okay to
tell them that a serious incident did take place and that your investigation
will be taking place within a few days and that you will keep them posted
regularly on the status of that investigation. Let them know that you are doing
this to help ensure that similar events will be prevented in the future. You
need to show honesty, contrition, and empathy in order to
build a trusting relationship with that patient or family. If you wait to
disclose that an incident occurred, the patient or family is likely to find out
about it in other ways, your credibility will suffer, and you will lose the
opportunity to develop a rapport with them.
Kaldjian notes that
a variety of strategies may be used to help train clinicians for the process:
didactic lectures, videos, training-level-appropriate clinical scenarios,
discipline-specific considerations, role play (preferably with realistic
simulated settings), standardized patients, patient perspectives, and
assessment of error disclosure skills. We like using simulations. While some
will use actors during the simulations, we prefer that the “actors” be
experienced clinicians who have participated in real life disclosure and
apology sessions.
When to begin training for disclosure and
apology is not clear. We think it should begin in medical school, where
we need to make it clear that errors will occur and prepare medical students to
recognize errors and understand what to do when errors occur. But, we think the most important training should take place during
residency. The ACGME (Accreditation Council for Graduate Medical Education)
has a core requirement for residency programs to incorporate training in error
disclosure. It states “Patient-centered care requires patients, and when
appropriate families, to be apprised of clinical situations that affect them,
including adverse events. This is an important skill for faculty physicians to
model, and for residents to develop and apply.” It requires that all residents
must receive training in how to disclose adverse events to patients and
families. Furthermore, residents should have the opportunity to participate in
the disclosure of patient safety events, real or simulated.
We cannot overemphasize the importance of
role models in this regard. The response to errors is molded by how
residents perceive their attendings and mentors respond to errors.
Unfortunately, that has not always been productive. When attendings are
hesitant to reveal errors to patients and families, residents pick up on that
and may adopt similar attitudes toward disclosure. On the other hand, seeing an
attending physician be forthright in disclosure and meet with patients or
families in a respectful, compassionate manner can positively impact a
resident’s attitude toward disclosure and apology.
Borz-Baba et al. (Borz-Baba 2020)
conducted a cross-sectional survey of medical residents in the Yale Primary
Care Residency Program, who were working in a community hospital in an
underserved area. They observed that 62.5% of the residents were not familiar
with the error-reporting process at their institution. General concerns about
disclosing errors were related primarily to negative patient reactions (66.7%).
The majority (58.3%) of the trainees' negative psychological experience after
an unanticipated outcome resulting in harm has caused increased anxiety about
future errors. Residents also expressed concerns about malpractice litigation, professional
discipline, and harm to professional reputation.
While a majority of
the residents were hypothetically familiar with the steps necessary to disclose
medical errors, none had undergone training in disclosure. There is a gap
between the hypothetical attitude and real practice. Their hospital did have in
place a policy for disclosure of the outcome of care but there was no formal
process that clarifies what information the patient communication should
contain. The authors state this reveals the “need for a more comprehensive
program that addresses the pre-disclosure action plan, the content of the error
disclosure, and the techniques to be adopted for delivering a well-formulated
message”.
Borz-Baba et al. recommend
the implementation of both lecture-based educational strategies and
simulated patient-training sessions. The lecture-based educational sessions
would include an e-learning session that will review the definition and types
of errors, the disclosure conversation process, and disclosure content. This
would be mandatory for all medical residents in the first year of training.
Yearly conferences would revisit the reporting system used at their institution
and a practice session with core teaching to promote a positive role-modeling
approach. They would also present and discuss the pre-disclosure and
post-disclosure support system developed with the participation of risk
management. The standardized patient-simulation session would briefly
review the content of the disclosure discussion and the message errors to
avoid. This would be followed by actual practice, reflection on the discussion,
and feedback sessions on the performance. Simulation of real-life experience
would allow trainees to become more confident with the conversation flow
and prepare them to embrace an attitude or style that emphasizes
preserving a trustworthy patient-doctor rapport.
Our June 22, 2010 Patient Safety Tip of the
Week “Disclosure
and Apology: How to Do It” included
examples from the Harvard and Canadian guidelines (listed below) of the types
of words and phrases that should and shouldn’t be used in communicating with
patients and families after a medical error has occurred.
We always remind all of the old adage “90% of communication is non-verbal”.
That point should be included in all your simulations and other training
activities on disclosure and apology. The critical importance of “body
language” in fostering trust during these discussion with patients and
families cannot be overstated. So, it is important in critiquing simulation
exercises that attention to body language is as important as attending to the
words actually spoken.
Having real patients or families who have
experienced a medical error discuss their experience is very
useful. We can usually find families who have had a positive experience
willing to speak to students or residents. But we can probably learn even more
from those families whose experience with the process was unsatisfactory.
The organizational culture is equally
important. We’ve seen too many organizations dominated
by attorneys whose attitude has been “say as little as possible”. Fortunately,
the literature over the past 2 decades has shown that disclosure and apology has
resulted in less litigation expenses and settlements, while maintaining the
trust of patients and families.
In fact, that trust
is far more important than the direct financial issues resulting from adverse
medical incidents. Prentice and colleagues studied the long-term impact after a
medical error and its relationship to how openly healthcare providers
communicate (Prentice 2020). They did a survey in Massachusetts
assessing experience with medical error and re-contacted respondents several
years later and assessed “open communication” with six questions assessing
different communication elements. Of respondents self-reporting a medical error
3–6 years previously, 51% reported at least one current emotional impact; 57%
reported avoiding doctor/facilities involved in error; 67% reported loss of
trust. Open communication varied: 34% reported no communication and 24%
reported ≥5 elements. Respondents reporting the most open communication
had significantly lower odds of persisting sadness (OR=0.17), depression
(OR=0.16) or feeling abandoned or betrayed (OR=0.10) compared with respondents
reporting no communication. Open communication significantly predicted
less doctor/facility avoidance, but was not associated
with medical care avoidance or healthcare trust.
Our many prior columns have also discussed
the trend toward using “communication-and-resolution” programs (CRP’s). After
an initial flurry of positive reports on the success of
communication-and-resolution programs, other reports did not paint as rosy a picture.
Mello and colleagues (Mello 2020) did
a comprehensive review of the factors contributing to success of these
programs. They found facilitators of success:
- the
support of top institutional leaders
- heavy
investments in educating physicians about the program
- active
cultivation of the relationship between hospital risk managers and representatives
from the liability insurer
- the
use of formal decision protocols
- effective
oversight by full-time project managers
- collaborative
group implementation
- small
institutional size
Gallagher et al. (Gallagher 2020) make a point we thoroughly agree with: trying to “market” CRP programs by highlighting
potential fiscal savings is not likely to be productive. They state “Honesty, transparency
and an overriding urgency to improve the safety of clinical care represent
goals with intrinsic value and resonate with patients, caregivers and
healthcare organizations alike. When those goals and values, not dollars, sit at
the center of an organization’s efforts, it is far more likely that an authentic
CRP will take hold.” We couldn’t agree more. We do
disclosure and apology because “it’s the right thing to do”. If you are
contemplating developing a CRP program, keep your core values as the main impetus.
Equally important is organizational training
to recognize what clinicians involved in medical errors (the “second victims”)
go through. All too often those clinicians, already riddled with guilt, become
isolated or even ostracized because of lack of support from their colleagues,
peers, and organization. Incorporating into the training on disclosure comments
from such “second victims” can be very beneficial when
it demonstrates how clinicians felt better about themselves after successful
disclosure and apology.
We always seem to be talking about hospitals
in our discussion on medical error disclosure and apology. Kaldjian
is quick to point out that medical errors occur in all venues of care, not just
inpatient care. So, it is equally important to take into consideration how to prepare
for and handle such discussion when they occur in outpatient settings and other
venues. And all specialties must adopt disclosure and apology approaches,
even those in which the opportunity to develop a rapport with the patient is
less likely, such as pathology and radiology. Brown et al. published an
excellent review of the barriers involved in radiology error disclosure and
steps that need to be taken to get the issue into the mainstream of radiology
practice (Brown
2019).
How is your organization ensuring that your
physicians are proprerly prepared for communicating
with patients and families after a medical error?
Some
of our prior columns on Disclosure & Apology:
July
24, 2007 “Serious Incident Response Checklist”
June
16, 2009 “Disclosing Errors That Affect Multiple
Patients”
June 22, 2010 “Disclosure
and Apology: How to Do It”
September
2010 “Followup to Our Disclosure and Apology Tip of the
Week”
November 2010 “IHI:
Respectful Management of Serious Clinical Adverse Events”
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 “Disclosure
and Apology: The CANDOR Toolkit”
August
9, 2016 “More on the Second Victim”
January
3, 2017 “What’s
Happening to “I’m Sorry”?”
October
2017 “More
Support for Disclosure and Apology”
April
2018 “More
Support for Communication and Resolution Programs”
August 13, 2019 “Betsy Lehman Center Report
on Medical Error”
September 2019 “Leapfrog’s
Never Events Policy”
Other very valuable resources on disclosure and apology:
- IHI’s
“Respectful Management of Serious Clinical Adverse Events” (Conway
2010)
- The
Canadian Disclosure Guidelines (Canadian
Patient Safety Institute 2008)
- The
Harvard Disclosure Guidelines (Massachusetts
Coalition for the Prevention of Medical Errors 2006)
- The
ACPE Toolkit (American
College of Physician Executives)
- Oregon
Patient Safety Commission Oregon
Adverse Event Disclosure Guide.
Some
of our prior columns on “the second victim”:
- December 17, 2013 “The Second Victim”
- July 14, 2015 “NPSF’s RCA2 Guidelines”
- June 2016 “Disclosure
and Apology: The CANDOR Toolkit”
- August 9, 2016 “More on the Second Victim”
- August 2017 “ROI
for a Second Victim Program”
- April 2018 “Joint
Commission and the Second Victim”
References:
Our “Serious Event
Response Checklist”
https://patientsafetysolutions.com/docs/Serious_Event_Response_Checklist.htm
Kaldjian LC.
Communication about medical errors. Patient Education and Counseling 2020;
Published online November 28, 2020
https://www.sciencedirect.com/science/article/abs/pii/S0738399120306595?via%3Dihub
Borz-Baba C,
Johnson M, Gopal V. Designing a Curriculum for the Disclosure of Medical
Errors: A Requirement for a Positive Patient Safety Culture. Cureus 12(2): e6931 February 10, 2020
Prentice JC, Bell SK, Thomas EJ, et al
Association of open communication and the emotional and behavioural
impact of medical error on patients and families: state-wide cross-sectional survey.
BMJ Quality & Safety 2020; 29(11): 883-894 Published Online First: 20
January 2020
https://qualitysafety.bmj.com/content/29/11/883
Mello MM, Roche S, Greenberg Y, et al. Ensuring
successful implementation of communication-and-resolution programmes.
BMJ Quality & Safety 2020; 29(11): 895-904
https://qualitysafety.bmj.com/content/29/11/895
Gallagher TH, Boothman
RC, Schweitzer L, et al Key marketing message for communication and resolution programmes: the authors reply. BMJ Quality & Safety 2020;
29(9): 779 Published Online First: 12 June 2020
https://qualitysafety.bmj.com/content/29/9/779
Brown SD, Bruno MA, Shyu
JY, et al. Error Disclosure and Apology in Radiology: The Case for Further
Dialogue. Radiology 2019; 293(1): 30-35
https://pubs.rsna.org/doi/full/10.1148/radiol.2019190126
Print “PDF version”
|
|
http://www.patientsafetysolutions.com/