The Power of an Apology in Medical Errors - Essay Example

Write your here Your first and here Your mentor 11 February, 2007 The Power of an Apology in Medical Errors The medical profession is probably the most demanding, and at the same time, the most fulfilling profession known to man. The ability to save lives and to improve the quality of life is the purpose for which medicine was created. Physicians, the members of this profession, are bestowed with the most difficult task amongst the human kind and that is to care for another life. In many respects, they belong to a class of people, who like parents, have the responsibility to take care of the life and welfare of other people. But it must be considered that doctors are, in the end, not gods. They too make mistakes, as it is human to do so. Unfortunately, when doctors make mistakes during treatment, the consequences can be severe. Sometimes, they can even result in serious injury or even death. In recent years, health care providers have become cautious about offering expressions of empathy or sympathy to patients whose disease did not have a successful outcome. These unsuccessful outcomes may be the result of known complications, clear errors, or other circumstances. The health care providers' caution in this area of communication is the result of the increasing number of lawsuits filed against them by their patients. Physicians understandably have a difficult time determining appropriate communication techniques to convey concern for the patient without inadvertently implying their own fault or guilt. It is not unusual for a physician's compassionate and empathetic actions to be misunderstood and later described to a jury as an apology for his error. Unquestionably, there are situations in which clear errors have been committed. Although rare, those events should certainly be followed with a sincere apology and appropriate assistance to the patient. In situations where the physician is not at fault for the undesired outcome, or when responsibility is difficult to determine prior to an investigation, it is still important for physicians to have the skills necessary to express empathy and concern without suggesting to the patient that they bear legal responsibility. Recent studies have suggested that failing to apologize for clear errors may prompt more claims than previously suspected. Research suggests that apology plays an important role in professional relationships. If done properly, an apology may not even be an issue in a subsequently filed lawsuit. Additionally, it is just common sense that demonstrating empathy and concern for patients during their most difficult times is the right thing to do. If lawsuits are subsequently filed in such situations, physicians will be seen in a much more favorable light if they have attempted to show appropriate concern and interest in their patients' well being. Many physicians are wondering about the purpose of expressing their remorse to a patient over a bad outcome or untoward incident. Indeed, there are large moral as well as ethical components to this issue. Doctors are also human, and every human has the need to convince themselves that at the end of the day, they did what was morally right. The human conscience may not give the physician in question a peace of mind if they fail to heed the inner voice that wants them to express their feelings of concern. This may apply not only to cases of malpractice where the patient is severely injured or even death occurred, but also in cases where there are not visible consequences. When an apology is truly warranted, accepting and expressing responsibility by the physicians for his or her mistakes is the first step to forgiving themselves and is the most likely way to maintain a good relationship with your patient. Demonstrating true sadness of the physician to the patient for his pain will help him and will strengthen the bond between physician and the patient. It is important for patients to feel that doctors care about them. Patients who have good relationships with their physicians will more likely forgive them in the event of an adverse outcome. Additionally, studies show that claims may be avoided by developing a good relationship with patients. It is known that in civil cases, juries have forgiven physicians when they believed the physicians tried their hardest, cared about their patients, and were honest when explaining the events. A good example of this is when in a trial where the jury returned a verdict in favor of the physician, one juror reported that he believed the doctor may have made a mistake but also felt the physician had done his best for the patient. On the other hand, juries tend to be harsh with physicians who appear to be uncaring and uncompassionate. It is determined that when something potentially bad has happened to a patient and he is aware of it, he wants his physician to explain it to him. Many attorneys state that evasive or defensive responses by a physician are primary factors in that turn patients into plaintiffs. The same attorneys claim that there are many cases in which the patient wanted to sue other physicians but didn't want his attorney to sue the one physician he felt was forthright, honest and compassionate about the incident. Although a sincere apology or expression of concern may not avoid a lawsuit, the failure to do so when indicated can certainly trigger one. True apologies are certainly warranted when clear medical errors have occurred. A good example is this: if a surgeon removes the healthy kidney in a patient, leaving the diseased kidney in place, the surgeon should immediately communicate the error and apologize. Fortunately, these situations are very rare. There are other cases in which the surgeon may feel responsible for the outcome of the surgery. Nevertheless, the bad outcome could also be the end result, even if the surgeon presented the finest and necessary care. Such an example is when a patient with multiple back surgeries could undergo spinal surgery performed at the wrong level because of a distorted anatomy. There are other cases when the patients' medical conditions are so complex that the actual injuries and diseases are unknown until much later, if they are ever discovered. In those situations, true apology is not warranted. However, discussion about the event and outcome as well as expressions of empathy by the physician is very important. In other situations, which are more common, an error may have occurred, but it may be not be the progenitor of a particular bad outcome. A typical example, a patient may have received the wrong dose of a medication. However, it may not be the direct cause of the injury. It is important for the patient to receive appropriate explanations regarding the injury and the physician should be involved in discussions to determine the cause and outline measures to resolve any problems. Likewise, the physician should express empathy and compassion regarding the situation. The apology given by the physician to the patient is of course, part of the relationship between the doctor and patient. But it is also known that many of the lawsuit are directed not only towards the physician that performed the operation and treatment, but the organization or hospital that that physician is a part of. The health care system is consistent not only of the physicians, nurses and hospitals, but also of the patients. They represent customers that demand the health services of doctors and hospitals. Therefore anything that influences the relationship between the physician and the patient will influence the entire system of health care demanded by the patient. This correlation is of great importance, since it determents the relationship between the health care provident and the future patients. It is evident that when lawsuit does occur, they decrease the reputation of not only the doctor, but also the entire health organization. The psychological effects of the apology will be an effective buffer against lawsuits directed towards the entire health organization, and therefore the organization will continue to provide health services to other patients. An effective and true apology will also reassure the patient that his interests were a top priority, and any bad outcome that has resulted of bad treatment is purely unintentional, and if possible, it will be remedied in the future. It will also effectively convince the patient that such outcomes will be more vigorously prevented in the future, therefore increase the quality of health care. There are many reasons for medical error disclosure, and these are often justified by potential cost savings, the belief in individual moral obligations in health care, and the concept that patients have rights and providers have responsibilities. Such an approach does not recognize the important quality role disclosure can play in a system of medical error disclosure, as well as the nature of error and the bad outcome. The entire system of health care can be improved by using a system of disclosure that provides education about the nature of the error, the mutual respect between the patient and the physician and integrates the patient and his or her family as a valuable partner in the error reduction enterprise. Clear disclosure policies and procedures are accentual and a program sensitive to patient and family needs, and is open to communications with committed and compassionate system representatives is vital. Use of mediation methods that foster communication, allow for venting, and are flexible in their approach to resolving conflict, including using apology. Such a system may improve a team approach to reducing errors and promoting patient safety. "Much of the literature on error disclosure focuses only upon the rights of the patients. Patients do indeed have rights, but with rights come responsibilities. A philosophy of partnership between providers and patients mandates that both engage in ensuring that the appropriate care is provided at the right place, at the right time, to the right person, in the safest and most efficacious manner possible"( Rosier F, 2000). "Beyond educating physicians about the nature of apology and its implementation, patients need to rely that they can contribute to reduce the possibility of mistakes. Indeed, there are many more patients than providers or administrators, so patients represent a potentially rich source of information due to their numbers and experience with the full spectrum of healthcare providers" (Liang BA, 2000). This requires a fundamental understanding between the provider and patient, perhaps best described as a "health care partnership agreement". Such an agreement should be provided at the begging of the treatment and be discussed by the patient with his or her primary care provider, and signed by both. Such an action would signify the importance of the agreement and provide opportunities for patients to be educated in the processes of care. This agreement could state that: "Medical care is complex and sometimes complicated. We believe that patients are an equal partner in the delivery of care and essential in improving the system. We will do everything we can to provide safe and effective care to you. As our partner, please ask any questions you have about your care, and in particular please let us know if you observe any mistakes in your care so we may use this important information as an opportunity to improve how we treat you and all patients. We want to work with you to make the best health delivery system for everyone! Thank you for your help and participation."(National Patient Safety Foundation, 2000) This agreement states that the patient himself is included in the system of healthcare and in preventing the possibility of mistakes. This approach also creates mutual trust, respect for the patient, an ideal of responsibility shared, and an improved therapeutic relationship based on open communication between providers and patients. "Disclosure of errors at the present time is generally haphazard; ad hoc methods, varying published approaches and, in particular, vague standards by accreditors all represent a poor means from which to learn from errors in an uncertain legal environment. Instead, a clear approach that provides information to the patient but avoids the ever present risk of shame and blame is essential" (Rosner F, 2000). This discussion will focus on disclosure of errors and adverse events that take place in hospitals, although the principles can be applied to other provider locations, errors that were unpreventable (such as drug allergies that arise on first administration), and near miss errors in an effort to obtain potentially useful system information from patients. It must be noted that although errors are often difficult to define, errors here that are the focus of disclosure are those which a risk management committee, peer review/quality assurance committee, and/or incident report identify as an error that either did or had a great risk of resulting in the loss of a patient's function, earning capacity, or life that mirrors that used by the Lexington VA system (Kraman SS, 1999). Near miss errors are included to provide opportunities for systems learning that may be important for potentially serious adverse events (Leape LL, 1994) which may be discussed with patients as part of the normal quality improvement process indicated above. These efforts must begin with a set of policies and procedures surrounding error that reflects the systems nature of it. Firstly, the policies and procedures of the entity must provide for an "error investigation team", perhaps as part of the standard peer review/quality assurance body within the facility. This team should have the relevant expertise to investigate errors that result in adverse events and those that do not; the composition must therefore be adjusted for the error in question. The investigation team should include some "on call" members who can be called on to begin assessment as soon as an error is identified, particularly an error that causes an adverse event. Secondly, these policies and procedures should provide for a "system disclosure team" comprising a high level representative of the administration, a patient care liaison, and a clinically trained individual in the relevant specialty relating to the potential error/adverse event, assuming disclosure will be to a patient or his/her family. The latter often ask clinically focused questions regarding the error so it is important to have a system representative present to answer such questions. The provider who last touched the patient should not be part of this disclosure, at least initially, since he/she is too close to the circumstance, may be experiencing tremendous emotional turmoil as a result of the error,( Wu AW, 2001) and will probably be ineffective in addressing it-at least in terms of the literature on communications effectiveness, medical education assessments on communication training, and the literature on breaking bad news to patients-if he/she has not been trained appropriately. Other disclosure systems such as the VA system in Lexington, Kentucky also do not initially include the providers involved in the incident (Kraman SS, 1999) Furthermore, the presence of the provider may incite high levels of conflict and devolve the disclosure effort into a finger pointing and blame reaction. The provider should be part of the investigation of the event, however, including important face to face encounters with patients during mediation, and hopefully this activity will allow him/her to sublimate the difficult emotional issues experienced into positive corrective action efforts. The potential conflict resulting from the presence of the provider leads to two relevant points. Firstly, some individuals affected by the error will be angry, will be strident and emotionally torn, and will generally be looking for culprits. It is essential that individuals who are part of the disclosure team understand that there will be significant emotional and at times hostile reactions by patients and their families to the error disclosure. Not all patients and/or their families will react in this manner, but the disclosure team must be prepared for this potential eventuality. Secondly, the individuals who represent the system in the error disclosure must be trained in communication and empathy; they must be concerned, committed, and compassionate; and, above all, they must not be defensive. It must be recognized that it is often not what is said but how one says it that predicts the listener's reaction. The relevant language, cultural values, and specific factors (such as communication aids for those with physical handicaps) should therefore be used to facilitate complete comprehension and discussion between the team and the patient/family. It is also essential that this team communication to the patient/family reflects a true sense of immediate and unceasing investigation of the event by all relevant parties until the situation is fully understood. Finally, the physician closest to the error may wish to participate in error disclosure; this should be encouraged, but, as noted, only if the provider is appropriately trained in the optimal sensitive methods of disclosing the error to the patient based on the appropriate literature. References: 1. Rosner F, Berger JT, Kark P, et al. Disclosure and prevention of medical errors. Arch Intern Med 2000; 160:2089-92. 2. Liang BA. Promoting patient safety through reducing medical error: a paradigm of cooperation between patient, physician, and attorney. S Ill Univ Law J 2000; 24:541-68. 3. National Patient Safety Foundation. Talking to patients about health care injury: statement of principle. 14 November 2000. 4. Leape LL. Error in medicine. JAMA 1994;272:1851-7 5. Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med 1999;131:963-7 6. Wu AW. A major medical error. Am Fam Physician 2001; 63:985-8. Read More