Q: What is the best way to tell a patient a medical error has been made?
A:
Dealing responsibly with medical errors
A simple, straightforward explanation and apology is more likely to benefit both patient and physician than is silence or an explanation that is convoluted or places blame.
A growing consensus recommends that when a medical error is made, health care providers should tell patients about the error and apologize.5 In part this recommendation stems from accepted ethical principles of respect for patients as autonomous decision-makers, and from the obligation of providers to act with beneficence on the patient’s behalf. If a medical error impacts the patient’s care in some way, the patient is unable to make informed consent about subsequent care or trust the medical provider if the error is not divulged.
Furthermore, others have advocated that an apology after a medical error can reduce the cost or risk of tort litigation for medical malpractice.6
To encourage admissions of error, many states now prevent apologies from being used in court as evidence of guilt in malpractice cases.
Although organizations and liability insurance carriers may have specific requirements or guidelines about how to handle medical errors, practitioners may want to consider the following steps:
- Get the key facts of what happened, if possible from those who directly observed or who were involved in the care
- Report these facts to risk management or to the professional liability carrier, according to internal policies
- Apologize to the patient.
Q: How do you apologize to a patient for a medical error?
A:
Important features of an apology
- Make the apology promptly
- Be sincere
- Apologize in person
- Keep it simple—eg, “I am very sorry for any concern or inconvenience this event caused you.” Avoid blaming others, minimizing the event, or giving an involved explanation about how the problem occurred.
The purpose of the apology is simply that: to apologize. A patient may need to process feelings about what happened, so the apology should be viewed as an important opportunity for the patient to heal.
After apologizing, reassure the patient that you plan to learn from the mishap and prevent further events from happening. Stress that the trust the patient places in you and your team is not misplaced; that you take all mishaps, even minor ones, seriously and have an aggressive program of quality assurance.
Finally, though you cannot undo the event, offering to waive your professional fee for the visit that led to the mishap will help rebuild patient confidence and loyalty.
Q: How do you learn from an outpatient office medical error to optimize patient safety?
A:
Learning from errors is a vital way we prevent errors from occurring in the future. Others have described key steps to creating a culture and process of improvement.7 These include:
- Establish an atmosphere of quality improvement in your organization by emphasizing that errors are inevitable, are more often caused by faulty systems rather than faulty people, and are opportunities to learn and improve.
- Avoid blame—search for root causes.
- Create a mechanism to report all errors, mishaps, “near-misses,” and unhappy customers, and a method to systematically review these reports to identify areas to improve.
- Incorporate “lessons learned” into system changes designed to prevent recurrence of this and similar mishaps.
Patient safety commentary
Openly acknowledging a mistake and apologizing to a patient, as the authors suggest, is sound advice increasingly followed in the United States and internationally. Disclosure of mistakes is a cornerstone of the safety work, as is being carried out in the United Kingdom by the National Patient Safety Agency (NPSA). They have prepared excellent online interactive educational materials to support health care professionals as they participate in the disclosure process.8
A second step the authors took was to learn about the inherent risks and potential failure points that are often deeply embedded in our care delivery processes. Mistakes are windows into the clinical work environment. If we peer through these windows regularly and systematically, we can learn a good deal about protecting our patients from harm. The mistake reported here—though of little or no harm to the patient (ie, possibly a near miss)—has potential as a rich information source about how care is delivered in the family practice clinic.9 In addition, because there was a recovery by the patient’s family physician, we have the added benefit of learning from that part of the narrative.
Learning from mistakes an intentional process, not an automatic one
First, an organization or setting must have a just culture to enable learning.10 Tools for assessing safety culture are available from the Agency for Healthcare Research and Quality (AHRQ)11 and from the Institute for Healthcare Improvement (IHI).12 A just culture is an essential attribute of a learning organization.13
Second, a systematic process must be available for inquiring about the root causes and contributing factors of events. Examples of such systems are those used by Veterans Health Administration (VHA)14 and the UK’s NPSA.15 The Medical Events Reporting System for transfusion medicine (MERS-TM) is a model reporting system in the US and is developed as a learning system.16,17
Third, we have learned that simply gathering information about the causes of events is not sufficient to prevent future events. Those involved in mistakes must be given an opportunity to come together to make sense of the causal information before they can make changes.
Fourth, a system-change method is needed to correct underlying causes. Such a method is the Plan-Do-Study Act (PDSA), which translates knowledge about causes into actions that can be implemented in the health care work environment.18
How might these processes apply to the case at hand
Two aspects of this case in particular bear scrutiny.
The clinic protocol. Protocols standardize care as well as complement the cognitive work required in clinical care. Understanding the contents and use of this protocol would shed light on this event. To what extent did the protocol support the interpretation of the TB test; how informative was it? Did it require obtaining a history from the patient as a component of the test interpretation? Did it detail the skills of the test interpreter? Did it spell out a contingency plan in the event those administering and reading the tests are unclear about the findings? Who had access to the protocol?
Handoffs, when things can get dropped. Another focus of this case is the 3 handoffs: the nurse reading the test handed the interpretation off to a physician; the physician handed the patient off to the public health clinic; and the clinic then handed the patient back to her primary care physician. Handoffs often lead to mistakes because they involve interpersonal communication and transfer of information, both of which are fraught with opportunities for errors.19
In the first handoff, we might well ask what information the nurse had about the patient’s history and what information she communicated to the physician? A full understanding of this handoff helps to make explicit hierarchical relationships in the clinic as well as information flow.
With the second handoff, we might ask what information regarding the uncertainty of the patient’s TB test interpretation and history were passed along to the TB clinic? How was the information communicated—on paper, electronically, by telephone? Each of these methods has unique constraints.
Finally, the fortunate third handoff—follow-up with the patient’s family practice physician that resulted in the discovery of the mistake and therefore recovery. It is particularly important to note that the recovery came because of an apparent system of feedback of information to the patient’s family physician. Such feedback loops contribute to safety. The family physician noticed something that did not make sense and investigated it. That is, the family physician was mindful.20 This attitude of mindfulness is a critical component in safe or reliable systems. Hubris is the enemy of safety.
Shirley Kellie, MD, MSc
Physician epidemiologist, American Medical Association