Download a PDF of the Current Issue 2015 Volume 12 Number 3 July- September

Communicating Adverse Events: The Art of Apologizing Without Admitting Liability

Karol DeVito, R.N. and Carol A. Austin
Reprinted with permission from MAG Mutual Insurance Company, Healthcare Risk Manager, Volume 7 /Number 14 2001
8-2-3 When a serious adverse event occurs, it is distressing to the physician, to the patient and to the patient’s family. While physicians know how to handle the clinical aspects of an adverse event, many are less clear about what to say and to whom. Expressing sincere sympathy and concern to the patient and/or family is often the most important response to help diffuse a potentially volatile situation.  The patient and/or family are due a prompt explanation. Many lawsuits are filed because patients are angry and confused when physicians do not communicate in a timely and appropriate manner after an adverse event. Repeated requests for an explanation of the event are a common reaction of upset patients and family members. Physicians should remain accessible for questions.   “Apologizing” to Patients   “Apology” does not have to mean an admission of wrongdoing or negligence. Rather, it can be an acknowledgment by the physician of shared regret over the outcome.  After an adverse event, organize a family meeting. Empathize with the patient and family without admitting liability. Statements such as “I am sorry that this happened,” or “I am sorry that you are in such pain” capture regret in a blame-free manner. Describe the event and medical response in brief, factual terms. If additional follow-up is indicated, discuss those plans with the patient.  Show concern for the patient’s condition. However, do not criticize yourself or other caregivers for a poor outcome. Do not point fingers at other physicians or healthcare providers. Do not engage in “thinking out loud” or speculation about what happened or why. An injured patient who feels that you did your best is not as likely to sue as an injured patient who feels deceived or abandoned by the physician. Such an apology will help you earn esteem with the patient and strengthen the physician-patient relationship.   Informed Consent   Usually an unfavorable outcome is the result of a known risk of the procedure and not the fault of the physician.  Key to an apology is the issue of informed consent. A well-received response will arise from a physician-patient relationship where the physician has worked at developing a solid rapport with the patient. In the event that a poor outcome does occur after having previously explained the major risks and complications of the procedure to the patient, there is a pre-established line of communication. This established line of communication allows for a conversation such as “I am sorry to say that your relative has suffered complications from the treatment. These are the problems we are facing and here is our plan.” This type of statement expresses regret, places no blame and conveys, “We are in this together.”   Preserving Evidence   As soon as possible after the event, factually record the event and medical response in the chart. Document plans for follow-up if indicated. Do not alter any prior documentation or insert backdated information. Record alterations can render otherwise defensible cases almost impossible to defend. An addendum is reasonable, as long as the addendum is designated as such and dated. Accepted rationale for an addendum would be for a correction of facts (i.e., persons involved, time of event, sequence of events) and for clarifying information. However self-serving, addenda added months after the event may be interpreted as an attempt to alter the medical record and will be used by the plaintiff’s attorney to support the plaintiff’s claim—so don’t do it.   Below are some risk management guidelines to follow after a complication or adverse event.

● personally let the patient/family know that a problem has occurred

● Offer an immediate explanation with ample time for discussion

● Explain the cause to the patient as accurately as possible. Avoid speculation

● never use words or expressions such as wrong, error, mishap, accident—all imply negligence

● never make disparaging comments about persons, products or organizations, or engage in “finger-pointing”

● Avoid characterizing complications or problems as unavoidable, extremely rare or extremely common

● do not belittle any complication

● Help the patient cope with bad results; discuss the next best treatment options, if applicable

● Keep the lines of communication open

    “The greatest problem in communication is the illusion that it has been accomplished.” —George Bernard Shaw