When and how do you tell patients about mistakes?
Question: Research seems to prove that patients want health care providers to admit their mistakes. The research even shows that patients are less likely to sue, even after a serious clinical error, if they are given a prompt, honest explanation of what happened. So does that mean you should tell patients about all mistakes, even if they might never know of them otherwise? And how do you go about telling them?
Answer: You should encourage clinicians to tell patients about almost any mistake, and they should do it as quickly as possible. That’s the advice from Albert Wu, MD, MPH, associate professor of health policy and management at Johns Hopkins University in Baltimore. He also is associate professor of medicine and an attending physician.
Wu has studied the issue extensively, and he agrees that patients put a high value on honesty and forthrightness. Besides being the right thing to do for the patient, admitting a mistake can have a profound effect on whether the patient feels ignored, tricked, or belittled emotions that are more likely to lead to a lawsuit than any clinical error, even if the error led to death or serious injury.
Wu can envision only one situation in which it would not be appropriate to tell patients of an error. If patients are emotionally fragile or in the middle of a life-threatening emergency, he says, it could be detrimental to their health to point out a mistake. In those rare cases, it would be better to wait or inform the patient’s family instead.
"But in general, you should always tell and do it as soon as possible," Wu says. "Any delay risks the perception that you’re attempting some kind of coverup. You get points by being forthright and as prompt as possible."
If the patient is deceased or incompetent, tell the family immediately about the mistake. Wu suggests that clinicians should hesitate only long enough to notify the facility’s risk manager that an error was made and that the patient or family must be told. But he cautions that risk managers should not act as roadblocks to disclosure. The risk manager should be present for disclosures of serious medical errors, but don’t make the clinician wait for an investigation before telling the patient or family.
"The risk manager may want to check up on a few things and prepare in some way, but don’t let that get in the way of prompt disclosure," Wu says. "Sometimes it might be enough for the doctor to just notify risk management, and they can tell him to go ahead."
Be honest and direct
How you go about telling the patient or the family about an error will vary in each case, but Wu advises being as direct and tactful as possible. Take essentially the same approach, whether you are disclosing a minor error with no serious implications or a major mistake. He offers these tips for how to break the news:
• Take the attitude that you are breaking bad news. Draw on your experience from other situations in which you had to tell a patient or family member of a bad prognosis, for instance.
• Tell the patient or family member that you have bad news to relate.
• State clearly that you, or someone else, made a mistake. Be tactful, but do not try to dance around the fact that a mistake was made. Do not let your own embarrassment make you less than honest in relating that something was wrong.
• Explain what happened, or as much as you know at that point. Use plain English and repeat the facts until the other person understands.
• Explain what the effect has been or will be for the patient.
• Tell the patient or family what is being done to correct the problem or what needs to be done. Be sure to explain that there will be no charge for services necessary to respond to the mistake.
• Apologize. This is an extremely important part of the conversation.
• Ask if there are any questions.
Remember that prompt and full disclosure does not prevent the patient or family member from getting upset. It is reasonable for them to express anger. If the mistake was serious, and the patient or family member is angry, this is a good time to turn the conversation over to the risk manager. In Wu’s experience, most people do not threaten litigation at this point, but some do, so it is good for the risk manager to step in.
Wu’s advice is much more than theoretical: He has used it himself. In one instance, he prescribed the wrong medication to a patient even though records indicated he might be allergic to it. When the patient questioned the prescription at the next visit, Wu immediately ’fessed up.
"I said, Oh, my God, that was a mistake. I shouldn’t have prescribed that to you. Thank God nothing happened. Let’s switch the prescription right now.’ I was very clear I’d made a mistake and felt bad about it."
The patient remained calm and told Wu the mistake was no big deal.
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