The clinician and patient experience
Who should I call after an adverse event?
Nearly every institution has a system in place for responding to adverse events. You should always notify your supervisor/attending of any potential adverse event, even a near miss. After that, in many cases, the first call goes to patient safety or risk management personnel working in the health care organization. A widely publicized and easily accessible number, available 24/7, can help clinicians reach help after an adverse event. In many instances, the responder is also trained in disclosure, and can provide “just in time” coaching to the clinician about next steps, and how to communicate with the patient and/or family after an adverse event.
At BIDMC, page Patient Safety at #3-HELP (34357) on weekday hours (M-F, 8-5). At other times, the Administrative Clinical Supervisor at #9-2465.
You do not need to discern whether the case is appropriate for CARe before calling for help. The Department of Patient Safety (or Risk Management) has many resources to offer to help with your initial communication to the patient about the error, support groups, and other resources that can be of use in any adverse event situation.
What is the process after an adverse event?
An adverse event typically triggers a series of events at the patient, clinician, and institutional level. The first step is to get help. If you are a trainee or student, tell your superior about what happened. Make sure the attending knows about the event before taking any further steps. If you are on faculty, contact the institutional patient safety and/or risk management leader designated for responding to adverse events. This communication ideally sets in motion a chain of events which may include all or some of the following (depending on the nature of the event):
- Disclosure coaching to guide the clinician about how to communicate about the adverse event with the patient and/or family
- Event analysis to determine what happened and why
- Peer support
(More information to be included shortly.)
What next steps are expected of me after an adverse event?
- Discuss with team members the factual details and sequence of what occurred and attempt to reconcile any opposing perceptions of what occurred.
- Document the adverse event in the medical record.
- Report the adverse event to the Department of Patient Safety.
- Make the initial communication to the patient/family as soon as practicable, ordinarily within 24 hours.
- Document the initial communication with patients in the medical record detailing who was present and what was discussed.
- Remain accessible for questions from the patient and family.
How do I decide if the incident meets the threshold for disclosure?
Although guidelines suggest communication with patients about harmful unanticipated outcomes, it can be challenging at times to determine whether an incident meets the threshold for disclosure. A first guiding principle is to avoid making this decision alone. The perspective of an objective “third party” can be very helpful.
Some “rules of thumb” that have been used include considering disclosure if: 1) you would want to know about the event had it occurred to you or a loved one; or 2) it will result in a change of treatment, now or in the future.
One approach that can help integrate disclosure into organizational culture is thinking about it as transparent communication. Rather than triggering a formal system each time, some disclosure conversations about minor events can be handled as part of routine care, at the frontlines of care by doctors, nurses, or other staff caring for patients. For example, telling a patient/family about delayed administration of an antibiotic may be accomplished by the bedside nurse, rather than necessarily requiring extensive coaching and a more formal meeting.
In some rare instances, clinicians may also struggle with deciding whether a disclosure may do more harm than good. Some events clearly meet the threshold for disclosure but pose unique ethical challenges because of concern that the disclosure might be harmful to the patient or family, or because the patient/family have been assessed to lack capacity to understand the conversation. Such situations should be viewed as the rare exception to the norm, and decisions to withhold or delay disclosure should be made carefully with input from an ethics advisory group, and documented carefully in the chart.
What do patients want after an adverse event?
Patients want open honest communication after medical error. Focus group studies show that patients want to hear:
- An explicit statement that an error occurred,
- What happened, and the implications for their health,
- Why the error occurred,
- How the mistake will be prevented in the future,
- An apology,
- Honest, empathic communication.
How do I approach communicating with a patient and/or family after an adverse event or medical error disclosure?
The first step to approaching a disclosure conversation is to get help. No matter how senior or experienced you may be, it is nearly always helpful to talk through and practice what you plan to say, with a coach or trusted colleague. Most health care organizations have guidelines for communicating with patients and families after adverse events and medical error.
Baystate Health, a CARe participant, provides a list of “do's and don’ts” for the disclosure process within this featured article.
For a discussion by Thomas Gallagher, et. al, on how challenging physicians find the disclosure conversation, click here.
The All Japan Federation of Social Insurance Federations provides guidelines for disclosure and apology in this document.
CRICO RMF provides Disclosure Guidelines and Policies here.
View a teaching module from the University of Washington on talking about harmful medical errors with patients.
These types of guidelines can be helpful to prepare for the conversation, conduct the discussion, and debrief and document after meeting with the patient and or family. Most sets of guidelines include details on:
- Getting help.
- Explaining what happened (facts as known).
- Describing the implications for the patients’ health and treatment plan.
- Offering genuine expression of regret/apology.
- Discussing the plan for investigation/analysis.
- Discussing how recurrences will be prevented.
- Establishing contact and supports for the patient and/or family so it is clear who patients and families should follow up with as questions arise.
While these are condensed principles of communication after harmful events, it is important to remember that disclosure is a process, not an event. Not all of these bullet points may be addressed (and perhaps should not be addressed) in the first conversation. But a commitment to follow up and attend to unaddressed issues above in a second or third conversation, as more information becomes available and/or as patients and families are ready to hear more, is critical to effective communication.
Will disclosure increase the likelihood of being sued?
Although some clinicians worry that open communication about and apology for error may increase liability, data suggest that full disclosure and apology may decrease liability. Studies such as this one published in the New England journal of Medicine and this one in The Lancet have shown that patients who pursue litigation often do so because they did not receive clear, empathic, and effective communication after an adverse outcome. They felt they weren’t told the truth, that no one took accountability, and want to prevent a similar incident from happening to another patient. They want to learn the whole story and receive an apology. On the other hand, mock jury trials suggest that in cases where full disclosure and apology are delivered, juries focus on meeting patients’ financial needs, whereas those cases without full disclosure and apology may prompt juries to consider punitive measures toward the physician or institution.
The Agency for Health care Research and Quality (AHRQ) shares some of the University of Michigan results, highlighting the reduction in malpractice claims as a result of their disclosure program.
What are some common disclosure pitfalls?
Communication after harmful events can be extremely challenging, even for experienced providers. Each patient and family member have distinct needs and reactions, and while guidelines can help guide the conversation, disclosure of medical error is at least partly an art form, requiring constant flexibility and adaptation. As part of national training of over 600 clinician leaders in disclosure, using simulated patients/actors for a live enactment of the conversation, a few common “pitfalls” have emerged (presented fully in When Things Go Wrong: Talking with patients and families about medical error, by R.D Truog, D. M Browning, J.L Johnson and T.G. Gallagher, Johns Hopkins University Press, 2011):
- "It's all my fault" or "It's all his/her fault." Clinicians struggle with culpability, and either “fall on the sword” – taking full responsibility for an error that may not have been their own – or blame others or the system, demonstrating inadequate accountability. Indeed, responsibility can be difficult to determine in an error that involves several team members and faulty systems – as many if not most do – but a key principle is to avoid blaming others and to take responsibility as an individual or a team or an institution, as appropriate.
- "Your loss is our learning opportunity." Another common pitfall is (over)-focusing on quality improvement, and assuring patients that the institution will learn from the mistake and make sure it doesn’t happen again. While these are important reassurances, timing is everything. In the wake of an error, focusing on QI to the exclusion of the individual patient’s needs and emotions can backfire.
- "All's well that ends well." In cases where no significant harm persists, clinicians can adopt an “all’s well that ends well” approach – indeed, relieved that the patient suffered no permanent harm. Still, the event is understandably concerning and frightening to patients, and may still require time and space for emotional reactions to what happened.
- "Just the facts..." Clinicians are encouraged to avoid speculation and focus just on the facts when discussing an adverse event with a patient or family member. However, some clinicians take this to an extreme, feeling nothing can be known for certain, and therefore impart little if any meaningful information to the patient. Patients and families need a plausible explanation of what happened, as soon as one is known. Avoiding speculation needs to be balanced with providing patients and families with a fair understanding of the event.
It is also important to avoid making value judgements as to who is worthy of disclosure and compensation and who is not based on perceived personality, character, finances, social status, marital and family situations, or race, gender, etc. While health care providers take very seriously their eithical obligation to treat all patients equally, it is not uncommon for these personal biases and attitudes to intrude during a time of crises and emotions where the provider's reputation and competency are challenged.
Listen to a CRICO audio file on Surgeons and Error Disclosure
How do I access peer support after an adverse event?
For an article on how patients, families and clinicians can move beyond feelings of guilt, fear and isolation, click here.
For an article on the importance of remembering that the provider who makes the mistake needs help, too, click here.
For clinician stories, services and resources, visit the For Clinicians page of the MITSS web site.
The CARe process
How will having the patient/family and attorney present at the explanation and apology conversations help the situation?
Health care organizations implementing CARe want to be honest with patients, and evidence shows that being honest about what occurred has positive implications for patient relationships, emotional well-being, and even for financial consequences. What we say to the patient during CARe meetings should be the truth, and the information should be no different than what would be revealed in a courtroom: if an error is made, it should be admitted in a CARe meeting as it would have in court. The benefit of CARe is that all legal and medical arguments and concerns from all parties will be aired together in a collaborative environment so that the patient can receive appropriate compensation in a timely manner.
How is the fault for the error apportioned with CARe?
This determination is a complex process involving an internal review which informs an insurer review. The insurer will use the hospital’s internal review, evaluation of the standard of care and causation of harm, and expert reviews to determine whether there will be any apportionment to the physician. Reviews are very thorough and the insurer will make efforts to ensure that the allocation is understood and accepted by the physician involved.
Will a financial offer paid to a patient through CARe be reportable on my National Practitioner Databank profile and Board of Registration of Medicine profile?
Yes, but only if the fault was apportioned at least partially to you, and not entirely to the system. The text of the Federal Liability Reporting Requirements and state provisions is available for download here.
Which parts of CARe will be discoverable in a court proceeding?
Patients are entitled to know the facts of their health care. Caregivers are encouraged to be empathetic and honest about the clinical details of a patient’s care, but should be careful to distinguish facts from speculation or premature judgments about the reasonableness of anyone’s care. Speculation and premature judgments can often be counterproductive and can even be harmful to patient and caregivers alike regardless of later admissibility determinations. The goal, of course, is to be honest and forthcoming, so admissibility may not play such a crucial role as it once did in claims or suits.
In Massachusetts, any statement of apology, regret, mistake or error is not admissible in court proceedings arising from the mistake or error unless a contradictory or inconsistent statement is made under oath. We recommend that statements of regret are used until all the facts are known about the event. The law is evolving and presently, it is not clear whether statements or explanations given during a CARe discussion will be later deemed admissible or will be seen to fall within the protected “settlement discussion” category.
Caregivers often lack pertinent details or are too close personally to a situation to be objective. Each case, at least in these early stages, will likely be unique. Admissibility determinations are always made after-the-fact. So please talk with your risk manager about any concerns you may have in approaching CARe conversations. When in doubt, get help.
Click here to view CRICO resources regarding adverse events.
Click here for the Coverys REACT program FAQ. (Respond Effectively and Communicate Timely.)