Adverse Events

The difficult task of simply disclosing bad news requires training and practice. Talking about an adverse event, particularly one involving error and resulting in serious injury, poses an even greater challenge. Physicians and other providers face these discussions knowing the harm was avoidable, and may feel personally responsible for an injury or experience guilt or shame about their role in the event. Providers also commonly worry about malpractice risk, and whether clear disclosures—and particularly apologies—increase liability risk.¹ In fact, proper disclosure can prevent lawsuits. Research showed long ago that victims who sue commonly mention four themes—seeking compensation, prevention of harm to others, accountability, and information.² Discussion in a proper communication and resolution program (CRP) would meet at least three of four needs by providing information, taking responsibility, and discussing prevention of harm to others. The University of Michigan experience with CRP showed a 50% reduction in claims filed and time to resolution, and about $2 million in annual savings.³ The University of Illinois experienced similar benefits, cutting claim rates in half while reducing legal and insurance costs.⁴ And a recent report on CRP implementation showed 43% of events with error were resolved with apology alone.⁵

Still, a combination of inadequate training and discomfort with disclosure results in unsatisfying conversations, unresolved concerns, unanswered questions, and lasting patient and family harm. Too often, physicians fail to disclose that an error occurred, how it happened, or how future events will be prevented.¹ For example, physicians addressing a hypothetical delayed diagnosis of cancer addressed emotion about half the time, addressed prevention of future events a fifth of the time, and took personal responsibility in less than a tenth of cases.⁶ Only 15% of patients expressed satisfaction with the disclosure process in early research² and satisfaction is likely similar in sites that have not established a robust CRP. How can that dismal statistic be improved, and what are the best ways to meet victims’ needs in these discussions?

What Victims Want

Victims’ needs and desires have been studied, and the lessons are clear—on the factual side, they want a full, honest, transparent disclosure of all harmful errors.^{1, 7, 8} They want to know what happened, why it happened, and what will be done to prevent a similar event from affecting someone else. On the emotional side, they want their feelings validated by being heard without interruption, empathetic communication, and a clear apology. This means an expression of concern (e.g.,“I’m sorry for your suffering”), but also a clear expression of responsibility (e.g., “We should have prevented this from happening”) including individual responsibility (e.g., “This was my responsibility and my mistake, and I’m sorry”). They want to know what’s going to be done for them, including corrective medical care and compensation. Many patients want to be involved in the management of the adverse event and safety improvements, and most appreciate the involvement of their attorneys in the meetings. Proper meeting preparation should plan to address these needs.

Review Harm Communication: Preparing for a Disclosure Meeting for information about planning and conducting harm communication meetings and improving harm communication education and processes in your hospital.