Disclosing an adverse event is a difficult and fearful event for healthcare providers. Nonetheless, disclosure of errors is required per professional, legal and regulatory standards. For example, if a patient falls during an assisted transfer and breaks a hip, disclosure is required. If a nurse gives expressed breast milk to the wrong NICU baby, disclosure must be made to both mothers. Some events, such as “never events” defined by the Centers for Medicare & Medicaid Services, also require reporting to regulatory bodies as well as disclosing them to the patient and/or family. Never events include hospital-acquired conditions such as ventilator-associated pneumonia.
When an error occurs
When an error occurs, it’s important to keep things in perspective. Human beings deliver medical services, so errors are inevitable. Be it major or minor, healthcare providers will likely make a mistake somewhere in their career, whether they know it or not. The main question is whether damage or loss occurs as a result. Because of our humanity, we must remain objective about our propensity to commit error and refrain from letting emotions carry us away. Noting mistakes and reporting them is the responsibility of all healthcare providers and fear should not prevent disclosure.
Errors can happen at every level of the healthcare continuum. When I was a nursing assistant in the hospital, I dumped a “hat” full of urine, which was part of a 24-hour collection test. There was no damage to the patient, but the test had to start all over again. Luckily, the findings were not of an urgent nature, but it was nonetheless a mistake. Even as a CNA, it was my responsibility to disclose to my supervisor what I had done. In this scenario, the physician was notified and the staff nurse disclosed the error to the patient.
I made an error as an RN when I transposed Tylenol #3 and Tylox medications to the opposite patients on an oncology unit. They both got pain medication, luckily without any adverse outcomes, but it was still a major narcotic medication error. I notified my head nurse and the oncologist for both patients immediately. In each case, the physician disclosed the medication error.
During my years in risk management, I was a part of disclosure teams where there were serious adverse outcomes. From experience, I can’t stress enough how important it is not to discuss the event until it is thoroughly investigated and disclosure well planned out. Trigger your chain of command if there is an event and do not speak to the patient or family unless instructed to do so.
I’ve seen staff nurses and even executive management, speak out of line and potentiate the legal damages. Don’t throw yourself, the doctor or the organization on the sword so to speak. If there is potential for a lawsuit, you don’t want to fan the flames by encouraging them to get a lawyer or by providing further damaging information that may or may not be accurate. Don’t draw yourself into a lawsuit by talking out of line.
Here are some questions related to error disclosure to consider.
Who should disclose the error?
For minor errors, disclosure may fall to the staff nurse but for more serious ones, it will be the responsibility of the nursing supervisor, department manager or director, nursing executive, executive administration, the physician, or any combination thereof. It depends on what the problem was, who made the error, and the extent of the loss or damage. A disclosure team may be formed including associated staff and management along with risk management personnel and/or the organization’s legal counsel, at least in the planning stage. Typically, the more devastating the damage, the more team members involved.
What should be done before the disclosure is made?
The most important thing about a disclosure is that it is well thought out and the conversation is planned. Communication is key. There must be communication between all parties involved, including the doctors, associated care staff, department managers, executive management, risk management, and possibly attorneys, before the disclosure meeting. Anticipate the questions that might be asked and prepare answers. Common questions are “Why did this happen?” “What care will be needed now?” and “How can this be prevented from happening to others?”
The goal of the disclosure team is to decide who will disclose, who will be in attendance, when it will be disclosed, what will be said, how it will be said, and what, if any, compensation will be offered. Compensation, in lieu of filing a lawsuit, might be anything from waiving charges associated with the event to a sum of money equal to the damage or loss. Disclosure is very difficult for a catastrophic case so planning and practice of the conversation is essential.
How should the disclosure be made?
Those responsible for disclosure must understand the difference between empathy and sympathy, especially in a seriously adverse outcome case. Empathy is the ability to understand another’s feelings whereas sympathy is having pity for them. It’s the difference between feeling sorry with them versus feeling sorry for them. You want to convey empathy by using words such as, “We’re sorry this happened”, not sympathy by using words such as “We’re sorry this happened to you”.
Empathy is important because we should be genuinely sorry about the incident and come across as such. However, care must be taken not to give the impression we owe them something for the error. Sympathy, by nature, wants to do something to make it up. When your best friend loses her mother, a sympathetic heart wants to do anything to make it better for her. With disclosure of an adverse event, we only want to convey sorrow for it happening.
The question of whether saying “I’m sorry” constitutes admission of guilt continues to be debated. Though many states have laws allowing physicians to say, “I’m sorry” without constituting admission of guilt, the fear of this verbiage among physicians is well founded. They have individual practice insurance to worry about. However, the risks of any treatment or procedure are previously made known to the patient or family and therefore, consent communicates their choice to take those risks. If one of the known complications happens, the disclosure need only convey, “I’m sorry this known complication happened”. What is important when saying, “I’m sorry” is to use the right wording, to say it with sincerity and to be clear what you’re sorry for.
What kinds of reactions can occur?
The disclosure meeting with the patient and/or family is likely to be emotionally charged, especially if family members you’re not familiar with may be present. The son who is coming into town for the meeting about mom may be the complete opposite of the quiet, understanding daughter whom mom lives with. All members of the disclosure team must stay in control of their emotions and their words. Do not match any anger, hostility or arrogance that may arise from the family. Be understanding and empathetic with their feelings. Remember, this is their loved one. Stay calm, be receptive to their questions and answer them as honestly, yet as defensively empathetic as possible. If you’ve done your pre-planning well, you will already have a script ready for their questions.
Most importantly, stick to the plan and verbiage decided on previously. This is not the point at which changing strategy would be a good idea, especially if first consulting with other team members would have been advisable. If something new comes up, say you’ll have to follow up on that issue and get back to the patient or family. Overuse of this tactic may cause patients and families to think you’re hiding something or being overly defensive. Your obligation here is to disclose the error, not have an answer for every single question that may arise.
Aftermath of mistakes
Healthcare providers wish they could be perfect all the time and never commit an error involving a patient. Unfortunately, that’s not reality. Mistakes do happen. We must do our best and learn from our mistakes. When things go wrong, we need to plan the disclosure well, have empathy for the patient and family and improve processes and systems to prevent future errors.
Vickie Myers is a legal nurse consultant.
Kachalia A. Disclosure of medical errors: Perspective. Perspectives on Safety. Jan. 2009. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=70. Accessed Sept. 6, 2011.
Wolf, ZR, Hughes RG. Chapter 35. Error reporting and disclosure. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, Md.: Agency for Healthcare Research and Quality. 2008. http://www.ncbi.nlm.nih.gov/books/NBK2652. Accessed Sept. 6, 2011.