Talking with Patients and Families about Medical Error: A Guide for Education and Practice

7. Practical Guidelines for Disclosure

74 In developing practical guidelines to assist and support coaches and clinicians, we began by reviewing and incorporating the information already available in the literature. Not surprisingly, a review of the ethics literature, empirical studies, and institutional policies suggests that while certain differences in approach exist, there is fairly widespread agreement about the elements that characterize good communication with patients and families that is likely to help preserve the patient-physician relationship and that may, at least in some cases, reduce the chance of legal action. For example, Gallagher notes that the following represents the minimal information that should be conveyed after an error has occurred: (1) an explicit statement that an error occurred; (2) a basic description of what the error was, why the error happened, and how recurrences will be prevented ; and (3) an apology.15,21 The consensus statement adopted by the Harvard teaching hospitals, in addressing the “who, what, and when” of disclosure, recommends the following components of the communication: (1) telling the patient and family what happened, (2) taking responsibility, (3) expressing regret and apologizing when there has been an error, and (4) explaining what will be done to prevent similar events in the future.6 The National Quality Forum (NQF) has developed a similar list of elements that should be a part of a conversation with a patient after an adverse event. In addition to the steps outlined above, the NQF recommends timeliness of communication; follow-up with the results of any investigation; emotional support of patients, families, and clinicians; and education and skill building associated with creating a program of systems improvement, with special emphasis on building a just culture.166 SEVEN Practical Guidelines for Disclosure PRACTICAL GUIDELINES FOR DISCLOSURE 75 Our guidelines for coaches and clinicians are also the product of our educational experience with health care professionals over several years. As a result of the ongoing dialogue between what we have taught and what we have learned, the guidelines have undergone a process of continual development and refinement. They are designed to be used as a “just-in-time” checklist. Many of the suggestions presume that someone has taken charge of the process and is able to provide guidance to the rest of the team. Ideally, this should be someone in a coaching role, but in hospitals that have not adopted this approach as an institutional model, it could be the attending or someone else in a position of clinical leadership . We refer to this person as the “coach,” recognizing that this role may be filled in a variety of ways. An abbreviated version of the guidelines is included in the appendix, but here we explore them in detail. First Priorities • Ensure that the clinical team stays fully attentive to the medical needs of the patient. In the immediate aftermath of an adverse event, clinicians may not be sufficiently focused on the patient’s medical needs, either because they are fearful of the patient’s reaction or preoccupied with the implications of the event for themselves. Therefore, the first question to address is: How is the patient doing right now and are all the medical issues receiving the full attention they deserve? • Ensure that key individuals are notified and involved as soon as possible, including the attending physician and the hospital risk manager. How far communication needs to go up the chain of command depends on the situation, the severity of the event, and the context. Since the cultural change we are trying to promote demands that transparency apply to all types of adverse events and medical error, disclosure should become standard practice for small as well as devastating errors. If a nurse’s workload causes a short delay in getting a patient the next dose of a pain 76 TALKING WITH PATIENTS AND FAMILIES ABOUT MEDICAL ERROR medication, a simple explanation and apology to the patient may be sufficient, without involving or notifying anyone else. However , clinicians need to be cognizant of which errors require prompt reporting (even on nights or weekends) as well as those that should be communicated at once to hospital leaders for their immediate attention. • Contact a designated “coach” and make arrangements for a meeting to plan disclosure. Again, while some events can certainly be managed by a simple and straightforward explanation to the patient, events that will have a significant effect on a patient’s care or outcome generally require thoughtful deliberation...