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1 Talking with Patients after a Medical Error: What to do? What to say? Julie Crosson, MD, Evans Educator Communication Skills Thomas Barber, MD, Evans.

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Presentation on theme: "1 Talking with Patients after a Medical Error: What to do? What to say? Julie Crosson, MD, Evans Educator Communication Skills Thomas Barber, MD, Evans."— Presentation transcript:

1 1 Talking with Patients after a Medical Error: What to do? What to say? Julie Crosson, MD, Evans Educator Communication Skills Thomas Barber, MD, Evans Educator, Department of Medicine ML Hannay, M.Ed., Communication & Leadership Specialist Medicine Grand Rounds, January 6, 2012 Boston University School of Medicine Thank you to The American Academy on Communication in Healthcare, and to Dr. Robert Truog, Exec. Dir. Institute for Professionalism and Ethical Practice, HMS

2 2 Disclosure I have made medical errors that affected patients.

3 3 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

4 4 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

5 5 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

6 6 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.

7 7 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.

8 8 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.”

9 9 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.”

10 10 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.

11 11 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?

12 12 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?

13 13 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

14 14 OLD LADY

15 15 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

16 16 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: S omething left undone, neglect of duty. -Institute or Medicine, To Err is Human Webster Dictionary

17 17 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.

18 18 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.

19 19 Disclosure GAP 90% of Doctors support the principle of disclosure but Only 30% actually do disclose

20 20 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

21 21 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

22 22 Full disclosure policy, University of Michigan NEJM, May 25, 2006

23 23 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.

24 24 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

25 25 What Information to Disclose Patients’ AttitudesPhysicians’ Attitudes Tell everything Choose words carefully

26 26 How to Disclose an Error Patients’ AttitudesPhysicians’ Attitudes Truthfully Compassionately Truthfully Objectively Professionally

27 27 Role of Apology Patients’ AttitudesPhysicians’ Attitudes Expected Concerned that apology creates a legal liability

28 28 When to Have the Conversation Patients’ AttitudesPhysicians’ Attitudes Immediately “When I have all the facts”

29 29 Back to the case….. The conversation

30 30 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

31 31 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

32 32 What are the steps for discussion?

33 33 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: x Prepare for strong emotions, both from yourself and patient/family

34 34 2. State What Happened -Simply -Slowly -Avoid medical jargon -Use pauses

35 35 3. Apologize -Focus on patient’s welfare -“I’m sorry”

36 36 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.

37 37 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

38 38 4. Take Responsibility Use “I” statements Do not blame or speculate Do not accept fault unnecessarily

39 39 5. Assurance The steps you are going to take to avoid this error occurring in the future

40 40 6. Invite questions 40% of patients stated they wished they had opportunity to ask questions “What questions do you have?”

41 41 7. Make a Follow-up plan Discuss together how to meet needs of patient and family Plan for next meeting Remain accessible

42 42 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

43 43 9. Debrief Back to self check-in Discuss with colleague Reflection helps us improve

44 44 The steps for discussion 1.Preparation- check-in 2.State what happened simply 3.Apology 4.Take responsibility 5.Assurance/Problem Solving 6.Invite questions 7.Make follow up plan together 8.Document 9.Debrief Gallagher, JCOM 2005l12l5:

45 45 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

46 46 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

47 47 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%)?

48 48 Verbal/Nonverbal Communications face to face conversation impact: % 25-35% 55-70%Words Tone of Voice BodyLanguage

49 49 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

50 50 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

51 51 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

52 52 What questions do you have for us?

53 53 “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

54 54 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

55 55 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

56 56 Future Opportunities : - Improving support systems for providers - Improving patient safety via greater transparency - Professional growth and improving our practice


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