Nearly 15 years after the IOM issued its groundbreaking "To Err is Human" report on medical errors, practitioners still question if an apology is appropriate.
Data suggests nurses carry the heaviest burden for communicating errors to patients and families, regardless of who committed the mistake.
"Reports suggest physicians are largely unaware if an error has occurred," said Sarah Shannon, PhD, RN, University of Washington. "It's up to nurse managers to create a culture where the incident report isn't viewed as a punitive mechanism. Supervisor and administration evaluations should not be tied to the number of incident reports."
In ambulatory care, Shannon said, errors are most frequently tied to missing labs or clinical information not ready in time for the patient's visit. In long-term care, resident or family complaints are tied to falls, pressure ulcers, poor nutrition or death, whether or not the medical care played a significant role in these outcomes, said Christy Crider, JD, head of LTC group at Baker, Donaldson, Bearman, Caldwell and Berkowitz. Poor communication, in any setting, communication is almost always at the heart of the matter, said Doug Wojcieszak, founder of the Sorry Works coalition.
"In long-term care, the relationship between the resident/family and the staff is both an advantage and a disadvantage," he commented. "The advantage is that bond between staff and the resident or family. If a disclosure isn't handled right, and the nurse you exchanged Christmas cards with for the past four years stops talking to you after dad falls, it makes the anger that much more intense."
Regardless of whether the blunder was clinical or just a breach in manners, experts use the term "service recovery" to rectify the relationship and work on the next step.
"It's always appropriate to say, 'I'm sorry this happened to you,'" said Shannon. "If you're certain you failed to give the medication or gave the wrong meds and are in the process of fixing potential harm, it's appropriate to say, 'I'm sorry I caused this problem.'"
It's also important not to diminish the apology by inserting a "but" anywhere in the conversation, which should happen within 24 hours.
Wojcieczak counsels clients to avoid prematurely admitting fault, but said clinicians should take extra steps to provide empathy, by finding a rabbi or minister, or helping with food or transportation needs.
After conducting an independent investigation, Wojcieczak said it's crucial to let the patient or family realize the therapeutic benefit of telling their side of the story.
Post-incident, the biggest mistake health professionals make is distancing themselves in the period before a settlement is reached.
"Make a point of following up with phone calls and emails," advised Wojcieczak. "Claims professionals see a million of these cases, but, to the family, it's the only thing in their life. If you're not talking to them, they find someone else to talk to."
A second person can be valuable to serve as a witness, offer moral support or mediate a heated discussion, said Wojcieczak.
Choosing Not to Disclose
In an era with apology protocols and disclosure programs at a growing number of facilities, there are still grey areas as to when an apology may not serve anyone's best interest.
Shannon said clinicians tend to disclose errors that are obvious to patients but "judgment errors" - like missing a lab test that might have disclosed a patient's condition earlier - are often kept silent.
"There are circumstances where disclosure and apology may do more harm than good," she explained. "As we know, most codes are unsuccessful. If an error is made, many are reluctant to go to the family with that information because the outcome wouldn't have changed."
Hospital and association policies don't always address what Shannon called the "gap between ethical beliefs and actual practice."
"It's not that people are bad, but circumstances are complex and good people struggle to do the best thing," she reflected.
Clinicians who issue an apology shouldn't expect "a big Kumbaya moment," said Richard Boothman, JD, associate professor in the department of surgery at University of Michigan Medical School, who conducted groundbreaking research on the facility's financial benefits when clinicians apologize.
"When the culture first started changing, we thought ourselves pretty noble for admitting we were wrong, but the conversations with families didn't go very well," he said.
Shannon agreed, counseling clinicians to get their hug from a co-worker after the apology conversation.
Though the conversation can be heated, it's never too late to apologize to a patient or family. Wojcieszak attested to the peace these disclosures can offer families or patients. His oldest brother died after a medical error in 1998 and his family successfully settled the case in 2000, but he didn't hear an apology until 2010. The hospital brought Wojcieczak on site, explained patient safety changes since the incident, and invited him to join quality committees.
"My family never expected an apology but it helped provide closure," he said. "It's also a big release for the person who caused the harm. I hear so many other cases where the healthcare worker can't get this incident out of her head or heart even 20 years later. It's never too late to say you're sorry."
Robin Hocevar is on staff at ADVANCE. Contact: RHocevar@advanceweb.com