1. Communication After Adverse Events
Seminar 9

2. Learning Objectives
Review barriers to effective communication after adverse events and ways to overcome them.
Discuss the steps involved in disclosing medical errors to patients and/or family members.
Demonstrate effective skills in disclosing of medical errors and adverse events.
Identify the process of reporting a medical error at each of the clinical rotation sites.

3. Do Patients Want to Know?1,2
Internal medicine patients surveyed about how they would want physicians to respond after an error.
98% wanted physicians to disclose even minor errors.
Patients also wanted “emotional support” from their physicians after an error.
Focus groups of adult patients found that patients wanted disclosure of all harmful errors, particularly:
what happened
why the error happened
how the error's consequences will be mitigated
how recurrences will be prevented

4. Do Physicians Disclose Adverse Events?3,4
Survey of medicine and surgery residents at Boston Medical in 2005
31% reported apologizing for the situation caused by the error.
Only 18% disclosed the actual error to the patient.
Survey of faculty, residents, and medical students in Midwest, Mid-Atlantic, and Northeast US
Over 90% said they would disclose a hypothetical major or minor error.
Only 41% had actually disclosed a minor error.
Only 5% had disclosed a major error.
19% admitted not disclosing an actual minor error.
4% admitted not disclosing an actual major error.
Reference 3. Residents asked if they’d had an error, circumstances of error (what happened, why they thought it happened, consequences to pt), whether they’d apologized for the consequences pt experienced, and whether they’d disclosed the actual error.
Reference 4. Survey asked if they’d disclose a hypothetical major or minor error, and then if they’d actually disclosed an error to a pt – large gap and unlikely that so many truly had not had a single error.

5. Do Physicians Disclose Adverse Events?5
35% of physicians and 42% of general public had experienced an error in their own or their family member’s care.
Only about 1/3 of those affected reported that the health care providers had disclosed the error to them or apologized.
“Thirty-five percent of physicians and 42 percent of the public reported that they had experienced an error in their own care or that of a family member. Eighteen percent of physicians and 24 percent of the public reported an error that had had serious health consequences, including death (reported by 7 percent of physicians and 10 percent of the public), long-term disability (6 percent and 11 percent, respectively), and severe pain (11 percent and 16 percent, respectively). About a third of the respondents in both groups who reported experience with an error said that the health professionals involved in the error had told them about it or apologized to them.”

6. Barriers to Communication after an Adverse Event6
Fears
Admitting responsibility for hurting someone
Anger from patients, their families
Reprimands from authority
Loss of job/position
Colleague disapproval
Negative publicity
Threat of medical malpractice claims
Lack of time
Do not think it will change the outcome
Can start with brainstorming with group what barriers exist to discuss a medical error
We’re all hardwired to want to avoid discomfort.

7. Overcoming Fears Culture of safety Accountability instead of blame
Recall that patients want honesty about errors
Discussion of error with patient often brings healing to the provider as well
If error truly due to educational gap, disclosure identifies gap so it can be filled
Helpful to emphasize here the concept of continuing medical education. Learning and filling gaps in our knowledge does not stop after medical school or residency.

8. Overcoming Threat of Litigation7
Effective communication is best asset against litigation.
Apologies actually reduce malpractice lawsuit risk.
Lucian Leape, MD: “Many believe that failure of communication, specifically the failure to acknowledge an adverse event and admit error, is the major cause of malpractice suits.”
Started discussion in seminar 4 on importance of effective communication.
Lucian Leape: known as the father of the modern patient safety movement in the US

9. Overcoming Threat of Litigation8
Survey of patients who did sue their providers showed that decision to sue was based on:
Original injury
Insensitive handling and poor communication
Four main issues patients want addressed:
standards of care (to prevent future similar incidents)
need for an explanation
compensation for losses
accountability from providers
8. “The decision to take legal action was determined not only by the original injury, but also by insensitive handling and poor communication after the original incident. Where explanations were given, less than 15% were considered satisfactory. Four main themes emerged from the analysis of reasons for litigation: concern with standards of care—both patients and relatives wanted to prevent similar incidents in the future; the need for an explanation—to know how the injury happened and why; compensation—for actual losses, pain and suffering or to provide care in the future for an injured person; and accountability—a belief that the staff or organization should have to account for their actions.”

10. Overcoming Threat of Litigation9
Over two-thirds of states have passed laws that make some apologies inadmissible in court as evidence of liability.
Consulting organizations exist to provide apology training to health care professionals in order to reduce malpractice cases.

11. Overcoming Time Barriers6,10
What steps should be involved in responding to an adverse event?
Care for the patient
Communicate with the patient
Keep it simple
Express empathy and compassion
Report to the appropriate parties
Check the medical record
Yes, it takes time, but if you go in with a rehearsed, effective approach (Lazare’s four part apology), it will be as concise as possible.

12. Overcoming Time Barriers10
Develop an effective method – Lazare’s Four Step Apology
Acknowledgement
Explanation
Expression of remorse and humility
Reparation

13. Overcoming Apathy – How Outcomes Do Change10,11
Apologies allow for healing – ten healing mechanisms identified by Lazare:
Restoration of self-respect and dignity
Feeling cared for
Restoration of power
Suffering in the offender
Validation that the offense occurred
Designation of fault
Assurance of shared values
Entering into a dialogue with the offender
Reparations
A promise for the future
Patients report improved patient-clinician relationship after full disclosure of errors.
Healing mechanisms affect both the patient and the health care provider
Patients were less likely to change physicians and report greater satisfaction and trust after full disclosure

14. Overcoming Apathy – How Outcomes Do Change7
Apology aids in the provider’s healing as well.
If a malpractice claim is still pursued, it is no longer about establishing blame, but rather about determining appropriate compensation.
No longer a focus on proving negligence
Judgments less costly

15. Role Play Small group role play with case scenarios:
Recall Pat Smith’s rash after being prescribed Augmentin.
Recall Pat Smith’s hospitalization for CHF exacerbation. She returns to clinic for post-discharge visit with fatigue. She has been taking both carvedilol and metoprolol due to unclear discharge instructions.
You are the resident who has to apologize and explain why she received Augmentin despite her allergy, or why her discharge instructions were unclear.
One resident will have the opportunity to act as the resident while another plays Pat Smith; resident role-player will receive feedback from the others, who will model different approaches. Even though you may not have been the person who wrote the discharge instructions, we work in health care teams and patient still deserves an apology. Have the residents break into pairs and practice the scenario twice so that each has the opportunity to play the resident PCP. Highlight the effective parts of an apology and the second victim issues.
*** Another option, if you have the resources available, is to have a standardized patient (SP) play Pat Smith for this encounter and videotape the sessions. We did this for our curriculum, having the residents scheduled in the simulation center lab for their SP encounter before seminar 9. In our encounter, Pat Smith had been admitted for the CHF exacerbation and had progression of her CKD to the point where she required initiation of hemodialysis. Due to an error in communication between the medicine, renal, and IR teams, the patient’s HD catheter placement was delayed by one day – causing prolonged hospital stay and affecting her ability to get to an important family event. The residents had to go in to explain to her why her procedure was being delayed and apologize. Then, instead of having residents role play at the end of the seminar, we had them play portions of their videos – we asked them to pick the part that was most difficult. Then we could discuss effective apology components. We reserved about an hour per resident (although arguably should take less time) when scheduling these session. This typically occurred between seminars 7 and 8 but could be done anytime after 7.

16. The Second Victim1, 12
75% of residents who reported they’d made an error were extremely distressed by their mistake.
After an error, physicians often feel
Guilt
A loss of confidence
Fear of future failure
Other negative emotions
Colleagues and employers rarely provide much needed support and affirmation.
A more recent article in Annals of Internal Medicine (Dec 20, 2016; v 165, n 12, pg 887-8) called “A Vulnerable Moment” may help facilitate a discussion here on culture of safety, second victim issues, and patient safety. It was not available when we did our curriculum but may be a useful resource now.

17. Error Reporting13
Integral part of determining where improvements can be made to increase patient safety and quality of care
Aids in identification of latent errors and system flaws
Residents who’ve received patient safety training are more likely to report errors

18. How to Report Errors
What should be reported into the safety monitoring system? Where do you find the error reporting systems at the sites you rotate in?
Must be tailored to each institution
Was discussed earlier in the curriculum (seminar 6); this is an opportunity to reiterate where to report, especially if there is a significant time difference between the two seminars.

19. References
1. Witman, et al. How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Archives of Int Med Dec 9-23;156(22):
2. Gallagher et al. Patients’ and Physicians’ Attitudes regarding Disclosure. JAMA Feb 26;289(8):
3. Kronman, et al. Factors Associated with Disclosure of Medical errors by Housestaff. BMJ Qual Saf. 2012; 21:
4. Kaldjian, et al. Disclosing Medical Errors to Patients: Attitudes and Practices of Physicians and Trainees. J Gen Intern Med Jul; 22(7): 988–996.
5. Blendon, et al. Views of practicing physicians and the public on medical errors. NEJM. 12 Dec 2002; Vol 347, No 24:
6. Federico F., Frankel A. PS 105: Communicating with Patients after Adverse Events [IHI Open School online course]. Cambridge, Massachusetts: Institute for Healthcare Improvement; August 4, Accessed March 2016.
7. Leape, L. Understanding the Power of Apology: How Saying ”I’m Sorry” Helps Heal Patients and Caregivers. Focus on Patient Safety: Newsletter of the National Patient Safety Foundation. 2005;8:1–3.
8. Vincent and Young.Why do people sue doctors? A study of patients and relatives taking legal action. The Lancet. 25 June 1994; Vol 343, No 8913:
9. Sorry Works! Making Disclosure a Reality for Healthcare Organizations.
10. Lazare. Apology in Medical Practice: an emerging clinical skill. JAMA, September 20, 2006; Vol 296, No 11:
11. Mazor, et al. Disclosure of Medical Errors: What Factors Influence How Patients Respond? J Gen Intern Med Jul; 21(7): 704–710.
12. Wu. The Second Victim. BMJ. 18 Mar 2000; Vol 320:
13. Jansma, et al. BMC Health Services Research 2011, 11:335.