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Talking with Patients after a Medical Error:

What to do? What to say?

Julie Crosson, MD, Evans Educator Communication SkillsThomas Barber, MD, Evans Educator, Department of Medicine

ML Hannay, M.Ed., Communication & Leadership Specialist

Medicine Grand Rounds, January 6, 2012Boston University School of Medicine

Thank you to The American Academy on Communication in Healthcare, and toDr. Robert Truog, Exec. Dir. Institute for Professionalism and Ethical Practice, HMS

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Disclosure

I have made medical errors that affected patients.

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Why a grand rounds on errors?

1. Increase patient trust

2. Decrease doctor isolation and burnout

3. Improve patient safety by talking to colleagues about errors to improve safety outcomes

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Overview

1. Present case of a medical error

2. Review current data on “Disclosure Gap”

3. Identify benefits and barriers to disclosure and apology

4. Review steps for talking about medical errors with patients and families

5. Reflect on the case

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Case presentation• 66 yr old man with complex PMH admitted to

medical service in May 2011 for nausea and abdominal pain.

• History of IDDM, CAD s/p CABG and AVR for AS, CVA, PVD, OSA, HTN, hyperlipidemia, anxiety, COPD w 50 pack-year tobacco history

• On 27 medications• Retired, worked unloading trains; lives w

daughter and wife

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History and Exam• Admitted for ? CVA vs. TIA 3/10. Since then, c/o

persistent nausea, burping, bloating and epigastric pain w/o vomiting. No change in diet or appetite. Normal BM. Confused about meds.

• VS: 197/115, 88, 20 (O2 sat 95% RA) Afebrile• Not acutely ill but uncomfortable. RRR S1S2

normal, 3/6 systolic ejection M, lungs clear, abd w active BS, soft, nondistended, nontender

• Labs: WBC 5.7, hgb 12.5, lytes normal, Gluc 266, amylase, LFTs, cardiac enzymes normal.

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Imaging• KUB moderate amount of stool, no

obstruction.

• CT abd/pelvis: no obstruction. Cholelithiasis, colonic diverticula w/o diverticulitis, rim enhancing splenic lesion likely hemangioma, oval soft tissue mass in RLL adjacent to the esophagus.

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Impression• Probable diabetic gastroparesis. He had been

prescribed metaclopromide but was unsure if he was taking this. – Metaclopromide, ondansetron, simethicone given– Control of hyperglycemia– Gastric emptying scan as outpatient– Lactose free diet

“Other issues per house staff. We will try to simplify his complex regimen but defer major decisions to his new PCP and his cardiologists.”

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Outcomes• Pt discharged after 36 hours, ? improved.• Frequent visits with PCP, endocrinology,

cardiology over the summer• Gastric emptying scan normal. • 23 lb unexplained weight loss between May and

September 2011: Weight loss w/up, including CXR 9/7 normal.

• 9/21/11 PCP paged me: “did you know about the mass in the RLL? It’s documented in the admit note and in the DC summary that this needed f/up. I didn’t know about it till today.”

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Readmitted to hospital• Pt readmitted to my service 9/21/11 for

urgent w/up. • CT chest w IV contrast: “interval growth of

the RLL spiculated, centrally necrotic soft tissue mass adjacent to the esophagus, now with possible invasion into the esophageal wall. Findings very suspicious for cancer.”

• Metastatic work up initiated.

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If you were Tom…

• What do you think you should do or say?

• What do you think you would do or say?

• What would your feelings/emotions be?

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What does a patient want/expect?

• If this occurred to your father/brother, how would he feel?

• What would he want/expect the doctor to do or say?

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Doctors’ Emotions

Dread

Fear of Punishment (sued)

Isolation

Guilt/Shame (harming a pt)

Anger (poor system set them up)

Powerlessness

Worry (job, reputation)

Self-doubt

“The Second Victim”Wu AW BMJ 2000;320:726-7

Patients’ Emotions

Dread

Fear (retribution form HCWs)

Isolation

Guilt (family: feel they didn’t keep close enough watch on the pt)

Anger

Powerlessness

Worry

NEJM 2007

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OLD LADY

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The Recent History of Medical Errors

IOM report 1999: ‘To Err is Human’

– 98,000 deaths/year due to medical errors

– Hospital Safety Movement, systems-based changes: EMR, procedure check lists

– ACGME competencies include quality improvement and improving patient safety

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Definitions A Medical Error : Failure to complete an action as intended, or the use of a wrong plan to achieve an aim. May or may not result in adverse outcome.

Unanticipated Outcome: A result that differs significantly from what was anticipated.

Omission: Something left undone, neglect of duty.

- Institute or Medicine, To Err is Human 1999- Webster Dictionary

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Patients’ Definition of Error

Physicians’ Definition of Error

Very broad,

includes some

non-preventable events,

poor service quality,

poor communication

Narrow,

only deviations from accepted standard of care

Gallagher et al. JAMA 2003;289:1001.

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Patients’ Expectations of Disclosure

Physicians’ Expectations of Disclosure

All errors that cause harm, including near-misses

Only errors that cause significant harm

Gallagher et al. JAMA 2003;289:1001.

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Disclosure GAP

90% of Doctors support

the principle of disclosure

but

Only 30% actually do disclose

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Barriers to Disclosure

- Skeptical of benefits

- Unnecessary distress to patient and family

- Patients unlikely to find out

- Lawsuits

- Lack of training in error disclosure

NEJM 2004

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Benefits of Disclosure

• Evidence suggests that skillful conversations and follow-up may reduce the risk of litigation

• Harvard Medical Practice Study only 3-5% of patients injured by negligent care actually sue, NEJM 2004

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Full disclosure policy, University of Michigan

NEJM, May 25, 2006

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Benefits of Disclosure

• Staying engaged with patients and restoring trust results in better outcomes for both patients and clinicians

• The right thing to do

Dr. Robert Truog, Institute for Professionalism and Ethical Practice, Harvard Medical School.

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What Is the Threshold for Disclosure?

“You would want to know about the event, if it had happened to you or a relative, or

It may result in a change in treatment, now or in the future.”

- Dr. Robert Truog, Executive Director

Institute for Professionalism and Ethical Practice,

Harvard Medical School

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What Information to Disclose

Patients’ Attitudes Physicians’ Attitudes

Tell everythingChoose words

carefully

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How to Disclose an Error

Patients’ Attitudes Physicians’ Attitudes

Truthfully

Compassionately

Truthfully

Objectively

Professionally

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Role of Apology

Patients’ Attitudes Physicians’ Attitudes

ExpectedConcerned that

apology creates a legal liability

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When to Have the Conversation

Patients’ AttitudesPhysicians’

Attitudes

Immediately “When I have all the facts”

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Back to the case…..

The conversation

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Next steps

• Primary data collected, information confirmed with PCP

• Evidence of failure to identify very abnormal radiologic finding and to communicate this effectively to PCP

• Requirement to disclose information to patient• Discussion with Risk Management• Stars report• Preparation • Meeting with patient and family• Documentation in record

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How is our patient now?

• Dx Squamous Cell CA Lung, locally advanced Stage IIIB (T4N1M0), on Gemcitibine protocol

• Tolerating chemo fairly well, but low functional status

• Weight 147 lbs on 1/3/11

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What are the steps for discussion?

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What are the steps for discussion?

1. Preparation•Self check-in•Seek assistance from trusted colleague•Review available medical facts•Consult risk management

– page 31-SAFE– Patient Advocate: x4-1778

•Prepare for strong emotions, both from yourself and patient/family

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2. State What Happened

- Simply

- Slowly

- Avoid medical jargon

- Use pauses

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3. Apologize

- Focus on patient’s welfare

- “I’m sorry”

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Two meanings of the words “I’m sorry”

1. Expression of compassion:

“I’m so sorry that this has happened.”

2. Expression of responsibility:

“I gave you the wrong dose. I am truly sorry.”

• The first is always appropriate• The second is appropriate only when it is true

Dr. Robert Truog, Institute for Professionalism and Ethical Practice, Harvard Medical School.

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How Apologies Fail• “If there was an error…”

• “There was a mistake, but…”

• “The mistake certainly didn’t change the outcome…”

• “Sometimes these things happen…”

Lazare JAMA 2006; 296:1401, Berlinger After Harm. Johns Hopkins, 2005

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4. Take Responsibility

• Use “I” statements

• Do not blame or speculate

• Do not accept fault unnecessarily

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5. Assurance

The steps you are going to take to avoid this error occurring in the future

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6. Invite questions

• 40% of patients stated they wished they had opportunity to ask questions

• “What questions do you have?”

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7. Make a Follow-up plan

• Discuss together how to meet needs of patient and family

• Plan for next meeting

• Remain accessible

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8. Document

• Rationale for clinical decisions

• Clinical outcome and plan of care

• Discussion with patient/family– Names/relationships of those present– Questions posed and the answers given

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9. Debrief

• Back to self check-in

• Discuss with colleague

• Reflection helps us improve

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The steps for discussion1. Preparation- check-in2. State what happened simply3. Apology4. Take responsibility5. Assurance/Problem Solving6. Invite questions7. Make follow up plan together8. Document9. Debrief

Gallagher, JCOM 2005l12l5:253-259

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How to take what you know into what you can do

You cannot force yourself to feel something you do not feel

But you can make yourself do right in spite of your feelings

Pearl S. Buck

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Build on what you already do

• You already use the skills--Giving bad news re: a diagnosis

• Instincts are to show empathy, to tell the truth, to listen to their fears

• Use the relationship building strategies that data shows work to enhance outcomes/compliance

• Build trust prior to as well as after an error

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Starting the conversation

• Set up—where, when, who?

• 1-1, Doctor/patient , start the conversation 30 seconds

• Debrief patient to doctor, 30 seconds

• What worked/didn’t work?

• Words, Voice Tone/Speed, Non Verbal?

• What % for each (must equal 100%)?

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Verbal/Nonverbal Communications face to face conversation impact:

0

10

20

30

40

50

60

7-15%

25-35%

55-70%

WordsWords

Tone of Tone of VoiceVoice

BodyBody

LanguagLanguagee

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Common Sense

• Is not common practice

• 80% of doing this well is

• Showing up to do it—with behavior that demonstrates your empathy, caring, and concern

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Authentic Apology: in addition to helping both doctor and patient heal….• …“nothing is more effective in reducing liability

than an authentically offered apology” Michael Woods, MD (Colorado surgeon)

• …my job is much more difficult when doctors fall on the sword….” “The hardest case for me to bring is the case where the defense has admitted error and apologized to the injured patient.” Andrew Meyer, Boston area Medical Malpractice lawyer

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In summary…• Talking about errors improves our relations with

patients

• Communication skills can be learned and improved with practice

• These conversations are complex and difficult,

use the self check-in and get help

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What questions

do you have for us?

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“A stiff apology is a second insult….

The injured party does not want to be compensated because he has been wronged; he wants to be healed because he has been hurt”

- G.K. Chesterson

England 1974-1936

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Building the Foundation of Trust

• What happens PRIOR to any error matters • Build a solid and positive relationship with the

patient, family members, & your medical team-- prior to any incident

• Patients see selves as equal, as partners/consumers/customers

• Use of internet—assume they have been/will be on it--they know your hospital ratings, errors history, etc.

• Litigation and lack of compliance continues with doctors who don’t apply basic relationship building skills

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7 Steps to defusing an angry patient/family member

1. Prevention: build trust beforehand

2. Acknowledge feelings/perceptions

3. No interruptions….Let them vent (rule of 3)

4. “Seek first to understand before being understood”….ask open ended questions

5. Offer AUTHENTIC apology

6. NO BLAME NO EXCUSES

7. Solve the problem: offer CHOICES, ALTERNATIVES, FOLLOW UP

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Future Opportunities :

- Improving support systems for providers

- Improving patient safety via greater transparency

- Professional growth and improving our practice