Choose words with care when apologizing for error
Risk managers have accepted, if not always embraced, the idea of admitting errors and apologizing after an adverse event, but figuring out exactly what to say can be a challenge. When done properly, an apology can help the patient and family while lessening the risk of a lawsuit. But a poorly executed apology can make matters worse.
The need for a carefully crafted apology after some adverse events is clear, says John Kador, a consultant in Winfield, PA, who coaches professionals on how to present an effective apology. He recently authored the book Effective Apology: Mending Fences, Building Bridges, and Restoring Trust (San Francisco: Berrett-Koehler Publishers; 2009). An apology is not always in order after a bad patient outcome, but it is always necessary after an error, he says.
"When there is a medical error, doctors who talk to patients, express sympathy, explain what happened, and even apologize have better outcomes than those who withdraw, deny, cover up, and stonewall," he says. "When we look at why patients sue doctors, it's almost always because the courtroom is the only place they can hear from the doctor about what happened. More and more hospitals and doctors are seeing the wisdom of communicating and disclosing."
Thirty-three states now have apology shield laws that keep sympathetic statements from being used against the doctor, which can reassure risk managers who fear that an apology will be used against them in court. But even without such a shield, Kador says risk managers should remember that apologizing typically does not encourage people to sue. It can, in fact, discourage litigation.
"I liken the decision to apologize to diving into a lake. There's some risk involved. It may be uncomfortable," he says. "Apology is not cost-free. It's just less costly than the alternatives."
Kador advocates that doctors and hospitals offer a full-throated apology that recognizes the harm done, accepts responsibility, and expresses remorse by using the words "I am sorry." The person apologizing also should indicate what has been learned from the experience and why the mistake won't be repeated.
"When doctors do that, as risky as it may seem, they find that their patients are not as punitive as they have been led to believe," Kador says. "But an apology is not a 'get-out-of-jail-free' card. You can't go into an apology thinking that you'll do this and be free of consequences. You should do it because it's the right thing."
Train for apologies
Monica Santoro, RN, CPHRM, CPHQ, senior vice president and senior consultant in clinical health care consulting for Marsh USA in New York City, has worked with multiple organizations facilitating the development of policies and procedures and conducting training programs on communicating with patients and families following adverse events and unanticipated adverse outcomes. She also implemented an effective procedure while serving as a risk manager at a tertiary care medical center.
Santoro says because these situations arise infrequently, many organizations have found it helpful to train a core group of clinical and administrative leaders in recommended best practices. These individuals are then able to brief the involved clinicians in preparation for a discussion with the patient and family. Considerations include whether you are dealing with an unanticipated adverse outcome and it is unclear what led to that outcome or whether you know from the outset that there was an error, such as wrong-site surgery or an unintentionally retained foreign body.
In the first instance, pending investigation, an expression of regret is appropriate, but an apology may be premature. In the case of an adverse event that resulted from a known error, the conversation should include: an apology; discussion of what this means for the patient in terms of future care and treatment; a commitment to look into what happened and why in order to prevent recurrence; an opportunity for the patient/family to ask questions; and contact information for the individual they should contact if they have additional questions.
"This is a complex issue, and there will be varying approaches and responses based on the specific situation. Frequently, more than one conversation is required," Santoro says. "It may be helpful to have a member of the clergy or pastoral care team in certain situations, as well as clinicians who can answer questions about the impact of the error on future care and treatment."
Consider the audience
The way you present information after an adverse event, including an apology, must take into consideration the other person's circumstances and needs, says Suzanne Miller, PhD, senior member in the Division of Population Science at Fox Chase Comprehensive Cancer Center in Philadelphia, where she also serves as director of the Psychosocial and Behavioral Medicine Program, director of the Behavioral Research Core Facility, and director of the Behavioral Center of Excellence in Breast Cancer. Miller also serves on the board of the HealthWell Foundation in Gaithersburg, MD. Remember that the purpose of the exchange is to engage in necessary dialogue for the patient or family's benefit, she says.
"You have to keep your own agenda and motivations out of it. You as the provider are not there to be forgiven, and your needs are not paramount," she says. "You need to function at the level of being the provider of information and support, not dealing with your own psychological issues. There are other ways to deal with your needs."
Miller and Kador offer these tips for an effective apology:
Do it in the proper surroundings. Don't have this conversation in an examination room, a hallway, or busy treatment area with people moving in and out. The setting should be calm and quiet so that both parties can concentrate on listening and understanding, Miller says.
Decide who should be included. The conversation might be appropriate with only the patient, or the patient may decide to include family members also. Also determine which caregivers should be included. The physician leading the care is an obvious choice, but nurses and others might also be appropriate, Miller says.
Understand your audience. Consider the patient and family members' education level, cultural differences, previous experience with your organization and other health providers, and any known biases. Tailor your conversation accordingly.
Choose your words carefully. Avoid blurting out anything, Miller cautions. Think through what you want to say, and enter the conversation with an agenda for what you want to say and how you want to say it.
Avoid using medical jargon. Speak plainly and don't try to gloss over bad information by using technical terms.
Make the apology personal. Use "I" instead of "we." Kador says the apology is much more effective and rings more sincere when a single person says "I am sorry" and "I will investigate this further" rather than the corporate "We're sorry." The other person wants to hear that an individual cares, not that the organization is issuing a statement.
Listen to the other person. Check frequently to determine if the other person understands you or needs more information. Also, check to see how much information the patient or family wants; some will want extensive details and others will want only the basics.
In particular, avoid saying "I know how you feel." That statement can rub people the wrong way. It is better to say something like, "I want to understand how you feel about this. Can you help me understand?"
Don't tiptoe around and issue what amounts to a nonapology. Trying to "apologize" without actually saying you're sorry only turns off the other person, Kador says. Avoid "if" statements such as "I'm sorry if you were hurt," or "I'm sorry if you were dissatisfied." Those are not real apologies, Kador says.
Similarly, avoid the passive voice: "Mistakes were made." Use an active voice to own the mistake and not sound wishy-washy: "I made a mistake," or "The lab made a mistake, and I'm sorry I didn't catch it."
"We just do ourselves a disservice by taking baby steps to apology. When anyone in health care does that, they are sure to infuriate those who were victims of the adverse event," Kador says. "There are no guarantees, except for this one: Offer a mealy-mouthed, cover-your-ass apology and your malpractice costs will go up."
Sources
For more information on apologies, contact:
John Kador, Consultant, Winfield, PA. Telephone: (570) -524-1207. E-mail: [email protected].
Monica Santoro, RN, CPHRM, CPHQ, Senior Vice President, Senior Consultant, Clinical Healthcare Consulting, Marsh USA Inc., New York City. Telephone: (516) 721-0207. E-mail: [email protected].
Risk managers have accepted, if not always embraced, the idea of admitting errors and apologizing after an adverse event, but figuring out exactly what to say can be a challenge.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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