1. SAYING SORRY IN CLINICAL PRACTICE R. Gyaneshwar Combined UOF/Sathya Sai Service Organisations Fiji Medical Seminar August 16, 2009.

2. R. Gyaneshwar2

3. 3 Case 1

4. R. Gyaneshwar4 Patient’s Perspective Baby damaged Baby damaged Doctor not competent Doctor not competent Doctor didn’t say anything Doctor didn’t say anything Doctor didn’t care Doctor didn’t care

5. R. Gyaneshwar5 Doctor’s Perspective I avoided a Caesar I avoided a Caesar Mother and baby are well Mother and baby are well Forceps marks are common Forceps marks are common How ungrateful can people be ? How ungrateful can people be ?

6. R. Gyaneshwar6 Who is Right ? The baby has a mark The baby has a mark The mother and baby are alive and well The mother and baby are alive and well

7. R. Gyaneshwar7 What About Consent ? When should we obtain consent? When should we obtain consent? What are our obligations legally/ethically? What are our obligations legally/ethically? Is a signed consent form essential? Is a signed consent form essential? What are the consequences of not getting consent? What are the consequences of not getting consent?

8. R. Gyaneshwar8 Informed consent More than a signed form More than a signed form Process of communication Process of communication Questions of detail Questions of detail - - Diagnosis - - Purpose of procedure - - Risks / benefits - - Alternatives

9. R. Gyaneshwar9 Material Risk High Court ( Rogers v Whitaker, 1992) High Court ( Rogers v Whitaker, 1992) Material risks are those to which a reasonable person in the patient’s position is likely to attach significance, or those to which the doctor knows or ought to know the particular patient is likely to attach significance.

10. R. Gyaneshwar10 When things go wrong Clinicians feel bad Clinicians feel bad Sense of vulnerability / fear Sense of vulnerability / fear Temptation to ignore or trivialise Temptation to ignore or trivialise Tendency to blame Tendency to blame Urge to run away Urge to run away

11. R. Gyaneshwar11 HINDSIGHT BIAS Before the Accident After the Accident Modified from presentation by Charles Vincent, Clinical Safety Research Unit

12. R. Gyaneshwar12 Patients Want : To know the truth To know the truth Have the Health authority accept responsibility Have the Health authority accept responsibility Apology for the hurt caused Apology for the hurt caused Apology from the doctor Apology from the doctor

13. R. Gyaneshwar13 What is the Truth ? Our perception is our truth regardless of the facts. Our perception is our truth regardless of the facts. Patients often believe that an unexpected outcome is due to MEDICAL ERROR Patients often believe that an unexpected outcome is due to MEDICAL ERROR Patient expectations are often unrealistic Patient expectations are often unrealistic ignoring side effects and complications ignoring side effects and complications

14. R. Gyaneshwar14 Saying Sorry ? Admission of fault ? Admission of fault Hence may lead to liability Hence may lead to liability Expression of sympathy for hurt caused Expression of sympathy for hurt caused Remorse for possible mistake Remorse for possible mistake

15. R. Gyaneshwar15 Sorry Works Coalition Reduces anger Reduces anger Reduces risk of law suits Reduces risk of law suits

16. R. Gyaneshwar16 Apology in Medical Practice Acknowledgement of event of injury Acknowledgement of event of injury Explanation of the circumstances Explanation of the circumstances Humility Humility Reparation Reparation Lasare, JAMA 2006, 296(11):1401-4.

17. R. Gyaneshwar17 When things go wrong ! What is our responsibility : What is our responsibility : - - to the patient ? ? - to ourselves ? What is the responsibility of the Medical Board ? What is the responsibility of the Medical Board ? What is the responsibility of the professional body ? What is the responsibility of the professional body ?

18. R. Gyaneshwar18 Why do people sue doctors ? Vincent C. Lancet 1994;343(1):609-13 Patients desire human interaction and communication when things have gone wrong. Patients desire human interaction and communication when things have gone wrong. Malpractice suits correlate poorly with actual occurrence of negligence Malpractice suits correlate poorly with actual occurrence of negligence Most patients injured don’t sue Most patients injured don’t sue Poor communication is a greater risk for litigation Poor communication is a greater risk for litigation

19. R. Gyaneshwar19 Medical Negligence Litigation Negligence is a claim that the doctor did not provide care to the standard expected by the law Negligence is a claim that the doctor did not provide care to the standard expected by the law Courts are guided but not bound by the standards of the profession Courts are guided but not bound by the standards of the profession

20. R. Gyaneshwar20 The law expects a doctor to exercise reasonable care and skill in providing advice and management

21. R. Gyaneshwar21 To err is human US Institute of Health 1999 US Institute of Health 1999 Kohn LT, Corrigan JM. To err is human : building a safer health system. Washington DC. National Ac press; 1999. “Mistakes are part of the human condition” “Mistakes are part of the human condition” Healthcare is a risky business. Healthcare is a risky business.

22. R. Gyaneshwar22 Conditions That Lead to Error Unfamiliarity with task (x17) Unfamiliarity with task (x17) Shortage of time (x10) Shortage of time (x10) Poor human equipment interface (x8) Poor human equipment interface (x8) Inexperience (x4) Inexperience (x4) Poor procedures (x3) Poor procedures (x3) Inadequate checking (x3) Inadequate checking (x3)

23. R. Gyaneshwar23 Making Us Safer Recognise limits Recognise limits Provide assistance - check lists Provide assistance - check lists Avoid interruptions Avoid interruptions Realistic workload Realistic workload Work within competence Work within competence Improved work environment/conditions Improved work environment/conditions

24. R. Gyaneshwar24 Understanding Medical Error Uncertainties of clinical practice Uncertainties of clinical practice - - Stressed staff - - Difficult patient - - Inadequate resources Nature of clinical decisions Nature of clinical decisions Activity levels Activity levels Time pressures Time pressures

25. R. Gyaneshwar25 Clinical Governance Model Education & Training Providing Quality Healthcare Risk Management Clinical Effectiveness Consumer Participation

26. R. Gyaneshwar26 Case 2 Instead of Hep B immunoglobulin, Anti-D given to baby Instead of Hep B immunoglobulin, Anti-D given to baby

27. R. Gyaneshwar27

28. How Is Safety Achieved? Analysing near misses Analysing near misses Reviewing adverse events Reviewing adverse events Errors/mistakes are opportunities for improvement Errors/mistakes are opportunities for improvement Establishing an environment which is patient focussed and safety conscious Establishing an environment which is patient focussed and safety conscious

29. R. Gyaneshwar29 Summary Talk / listen to your patients Talk / listen to your patients You are human, you will make mistakes You are human, you will make mistakes Learn from your mistakes Learn from your mistakes Be honest and upfront Be honest and upfront Don’t be frightened to say sorry Don’t be frightened to say sorry Maintain good clinical notes Maintain good clinical notes