Making a sincere apology for a medical error is no easy task, according to Wendy Levinson, MD, FACP, an expert on medical error disclosure. “I’ve run workshops with fake patients where the physicians are sweating as they practice this,” said Dr. Levinson, a professor in the department of medicine at the University of Toronto Institute of Health Policy, Management and Evaluation, during a session at Internal Medicine 2014 titled “Disclosing Medical Errors to Patients: Considering Where, When, and How.” In an error disclosure, patients want to hear an explicit statement that an error occurred, what happened and the implications for their health, why it happened, and how recurrences will be prevented in the future for themselves and other patients, she said. “And they want an apology. Not a statement of regret like, ‘I’m sorry this happened to you,’ but a statement such as ‘I’m sorry I caused you harm,’” Dr. Levinson said. Several groups around the world have studied the optimal way to disclose errors, she added. This work, from organizations such as the U.S. National Quality Forum, the Canadian Patient Safety Institute, and the U.K.’s National Patient Safety Agency, tends to have the following guidelines in common: Begin by stating there has been an error; Describe the course of events, using nontechnical language; State the nature of the mistake, consequences, and corrective action; Express personal regret and apologize; Elicit questions or concerns and address them; and Plan the next step and next contact with the patient. “This is harder than it sounds,” Dr. Levinson said. “I encourage you to do some role playing around error disclosure.” Errors by others One tricky issue is whether and how to disclose errors made by other clinicians. Ideally, your institution should offer guidance in how to handle this situation, and you should feel comfortable approaching your colleagues to discuss situations that arise. The disclosure strategy for errors by a colleague likely will depend on the clinical situation, such as whether it involved a physician with whom you were co-managing, or a trainee, or a clinician who didn’t have direct contact with the patient. In the case of co-managing physicians, both should participate in the disclosure regardless of who made the error. In the case of a trainee error, the attending physician and the trainee both should be involved, Dr. Levinson said. Attendings also should handle disclosure of errors made by a clinician who didn’t have direct contact with the patient, although the clinician who made the error should be invited to join if desired, she said. If the error occurred at another institution or is unrelated to current care, the disclosure should be handled by the medical director at the institution currently caring for the patient, after consultation with the clinician who made the error and/or with the outside institution, she said. Follow words with actions It’s important to remember, too, that the actions following an apology are as important as the words used in the apology, said co-speaker Thomas Gallagher, MD, FACP, professor of medicine and of bioethics and humanities at the University of Washington School of Medicine in Seattle. “We’ve often been too focused on the words we say to patients, but in some respects what’s more important are the broader set of actions that follow,” Dr. Gallagher said. Those actions can include institutional changes. Knowing that those are in the works can be a great comfort to patients, who often want to believe that their experience might lead to a positive change for others, he said. Institutions have begun to embrace the idea that errors are their responsibility as well as the responsibility of individual clinicians, Dr. Gallagher said. “Communicating with patients after an unanticipated outcome is now seen as a broader part of how we think about high-quality health care; it isn’t just about risk management,” he said. To make their disclosures high quality, institutions should be candid and transparent about unanticipated outcomes, conduct a rapid investigation, offer a full explanation, and apologize as appropriate, Dr. Gallagher said. Furthermore, where appropriate, the institution should seek to provide for the patient’s and family’s financial needs resulting from the error, hopefully without having to resort to litigation. And the institution should build systematic patient safety analysis and improvement into its risk management plan, he said. “Currently, ours is often a system of accountability that doesn’t adequately service the patient’s need for information, for our accepting responsibility, for timely compensation [when appropriate], and for a sense that we’ve learned from the mistake,” said Dr. Gallagher. “We need to demonstrate to the patient and the public that learning is happening; in many ways, this is the most important thing we miss.” source
