Transcript Talking to 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
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Disclosure
I have made medical errors that
affected patients.
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Why a grand rounds on errors?
1. Increase patient trust
2. Decrease doctor isolation and burnout
3. Improve patient safety by talking to
colleagues about errors to improve
safety outcomes
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Overview
1. Present case of a medical error
2. Review current data on “Disclosure Gap”
3. 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
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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
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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.
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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.
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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.”
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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.”
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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.
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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?
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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?
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Doctors’ Emotions
Patients’ Emotions
Dread
Dread
Fear of Punishment (sued)
Fear (retribution form HCWs)
Isolation
Isolation
Guilt/Shame (harming a pt)
Guilt (family: feel they didn’t keep
close enough watch on the pt)
Anger (poor system set them up)
Anger
Powerlessness
Powerlessness
Worry (job, reputation)
Worry
Self-doubt
“The Second Victim”
Wu AW BMJ 2000;320:726-7
NEJM 2007
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OLD LADY
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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
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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
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Patients’
Physicians’
Definition of Error Definition of Error
Very broad,
Narrow,
includes some
only deviations from
non-preventable events, accepted standard of
care
poor service quality,
poor communication
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Gallagher et al. JAMA 2003;289:1001.
Patients’
Expectations of
Disclosure
Physicians’
Expectations of
Disclosure
All errors that cause
harm, including nearmisses
Only errors that
cause significant
harm
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Gallagher et al. JAMA 2003;289:1001.
Disclosure GAP
90% of Doctors support
the principle of disclosure
but
Only 30% actually do disclose
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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
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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
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Full disclosure policy,
University of Michigan
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NEJM, May 25, 2006
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.
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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
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What Information to Disclose
Patients’ Attitudes
Physicians’ Attitudes
Tell everything
Choose words
carefully
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How to Disclose an Error
Patients’ Attitudes
Physicians’ Attitudes
Truthfully
Compassionately
Truthfully
Objectively
Professionally
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Role of Apology
Patients’ Attitudes
Physicians’ Attitudes
Expected
Concerned that
apology creates a legal
liability
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When to Have the Conversation
Patients’ Attitudes
Physicians’ Attitudes
Immediately
“When I have all the
facts”
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Back to the case…..
The conversation
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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
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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
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What are the steps for discussion?
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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
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2. State What Happened
-
Simply
Slowly
Avoid medical jargon
Use pauses
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3. Apologize
- Focus on patient’s welfare
- “I’m sorry”
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Two meanings of the words “I’m sorry”
1. 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
Dr. Robert Truog,
Institute for Professionalism and Ethical Practice, Harvard Medical School.
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How Apologies Fail
• “If there was an error…”
• “There was a mistake, but…”
• “The mistake certainly didn’t change the
outcome…”
• “Sometimes these things happen…”
Lazare JAMA 2006; 296:1401, Berlinger After Harm. Johns Hopkins, 2005
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4. Take Responsibility
•
Use “I” statements
•
Do not blame or speculate
•
Do not accept fault unnecessarily
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5. Assurance
The steps you are going to
take to avoid this error
occurring in the future
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6. Invite questions
• 40% of patients stated they
wished they had opportunity
to ask questions
• “What questions do you
have?”
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7. Make a Follow-up plan
• Discuss together how to meet
needs of patient and family
• Plan for next meeting
• Remain accessible
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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
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9. Debrief
• Back to self check-in
• Discuss with colleague
• Reflection helps us improve
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The steps for discussion
1.
2.
3.
4.
5.
6.
7.
8.
9.
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
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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
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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
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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%)?
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Verbal/Nonverbal Communications
face to face conversation impact:
60
55-70%
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25-35%
40
30
20
10
0
Tone of
7-15% Voice
Body
Language
Words
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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
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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
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In summary…
• Talking about errors improves our relations with
patients
• These conversations are complex and difficult,
use the self check-in and get help
• Communication skills can be learned and
improved with practice
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What questions
do you have for us?
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“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
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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
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7 Steps to defusing an angry
patient/family member
1.
2.
3.
4.
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
5. Offer AUTHENTIC apology
6. NO BLAME NO EXCUSES
7. Solve the problem: offer CHOICES,
ALTERNATIVES, FOLLOW UP
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Future Opportunities :
- Improving support systems for providers
- Improving patient safety via greater transparency
- Professional growth and improving our practice
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