Talking with patients after a medical error what to do what to say
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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

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Talking with patients after a medical error what to do what to say

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


Disclosure

Disclosure

I have made medical errors that affected patients.


Why a grand rounds on errors

Why a grand rounds on errors?

  • Increase patient trust

  • Decrease doctor isolation and burnout

  • Improve patient safety by talking to colleagues about errors to improve safety outcomes


Overview

Overview

  • Present case of a medical error

  • Review current data on “Disclosure Gap”

  • 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


Case presentation

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


History and exam

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.


Imaging

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.


Impression

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.”


Outcomes

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.”


Readmitted to hospital

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.


If you were tom

If you were Tom…

  • What would your feelings/emotions be?

  • What do you think you should do or say?

  • What do you think you would do or say?


What does a patient want expect

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?


Talking with patients after a medical error what to do what to say

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

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


Old lady

OLD LADY


The recent history of medical errors

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


Definitions

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: Something left undone, neglect of duty.

Institute or Medicine, To Err is Human 1999

Webster Dictionary


Talking with patients after a medical error what to do what to say

Gallagher et al. JAMA 2003;289:1001.


Talking with patients after a medical error what to do what to say

Gallagher et al. JAMA 2003;289:1001.


Disclosure gap

Disclosure GAP

90% of Doctors support

the principle of disclosure

but

Only 30% actually do disclose


Barriers to disclosure

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


Benefits of disclosure

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


Full disclosure policy university of michigan

Full disclosure policy, University of Michigan

NEJM, May 25, 2006


Benefits of disclosure1

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.


What is the threshold for disclosure

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


What information to disclose

What Information to Disclose


How to disclose an error

How to Disclose an Error


Role of apology

Role of Apology


When to have the conversation

When to Have the Conversation


Back to the case

Back to the case…..

The conversation


Next steps

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


How is our patient now

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


What are the steps for discussion

What are the steps for discussion?


What are the steps for discussion1

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: x4-1778

  • Prepare for strong emotions, both from yourself and patient/family


2 state what happened

2. State What Happened

Simply

Slowly

Avoid medical jargon

Use pauses


3 apologize

3. Apologize

Focus on patient’s welfare

“I’m sorry”


Two meanings of the words i m sorry

Two meanings of the words “I’m sorry”

Dr. Robert Truog,

Institute for Professionalism and Ethical Practice, Harvard Medical School.

  • 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


  • How apologies fail

    How Apologies Fail

    Lazare JAMA 2006; 296:1401, Berlinger After Harm. Johns Hopkins, 2005

    “If there was an error…”

    “There was a mistake, but…”

    “The mistake certainly didn’t change the outcome…”

    “Sometimes these things happen…”


    4 take responsibility

    4. Take Responsibility

    Use “I” statements

    Do not blame or speculate

    Do not accept fault unnecessarily


    5 assurance

    5. Assurance

    The steps you are going to take to avoid this error occurring in the future


    6 invite questions

    6. Invite questions

    40% of patients stated they wished they had opportunity to ask questions

    “What questions do you have?”


    7 make a follow up plan

    7. Make a Follow-up plan

    Discuss together how to meet needs of patient and family

    Plan for next meeting

    Remain accessible


    8 document

    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


    9 debrief

    9. Debrief

    Back to self check-in

    Discuss with colleague

    Reflection helps us improve


    The steps for discussion

    The steps for discussion

    Preparation- check-in

    State what happened simply

    Apology

    Take responsibility

    Assurance/Problem Solving

    Invite questions

    Make follow up plan together

    Document

    Debrief

    Gallagher, JCOM 2005l12l5:253-259


    How to take what you know into what you can do

    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


    Build on what you already do

    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


    Starting the conversation

    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%)?


    Verbal nonverbal communications face to face conversation impact

    55-70%

    25-35%

    7-15%

    Verbal/Nonverbal Communications face to face conversation impact:

    60

    50

    40

    Body

    Language

    30

    Tone of Voice

    20

    10

    Words

    0


    Common sense

    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


    Authentic apology in addition to helping both doctor and patient heal

    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


    In summary

    In summary…

    • These conversations are complex and difficult,

    • use the self check-in and get help

    • Communication skills can be learned and

    • improved with practice

    Talking about errors improves our relations with patients


    Talking with patients after a medical error what to do what to say

    What questions

    do you have for us?


    Talking with patients after a medical error what to do what to say

    “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 1974-1936


    Building the foundation of trust

    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


    7 steps to defusing an angry patient family member

    7 Steps to defusing an angry patient/family member

    Prevention: build trust beforehand

    Acknowledge feelings/perceptions

    No interruptions….Let them vent (rule of 3)

    “Seek first to understand before being understood”….ask open ended questions

    Offer AUTHENTIC apology

    NO BLAME NO EXCUSES

    Solve the problem: offer CHOICES, ALTERNATIVES, FOLLOW UP


    Talking with patients after a medical error what to do what to say

    • Future Opportunities :

      • - Improving support systems for providers

      • - Improving patient safety via greater transparency

      • - Professional growth and improving our practice


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