MEDICAL ERROR CONVERSATIONS Kathleen A. Bonvicini, MPH, EdD CRITICAL CONVERSATIONS & RELATIONSHIPS Introduction The successful veterinary practice depends on strong leadership, a motivated and multi-skilled health care team, and consistent policies and procedures for delivering a high level of client and patient care. All of these factors are dependent on good communication. There is strong evidence that communication has a significant influence on the quality and efficiency of patient care delivery. In human medicine, ineffective team communication was the root cause for nearly 66 percent of all sentinel events reported during the 10-year period 1995 2005 [1]. When health care team members fail to communicate effectively, patient care suffers. Providing training to improve health care team communication is a wise investment that can lead to satisfied clients and health care team members, healthy patients, and a successful practice. In human medicine, training to improve medical teamwork systems with communication improvement efforts has led to cost savings for the practice, sharp reductions in clinical error rates from 30.9% to 4.4% [2], and a 27% reduction in staff turnover [3]. Medical Error: Incidence in Practice While the incidence of medical errors in human medicine has been highlighted in national reports, research studies, and featured in nightly news broadcasts, the true incidence of errors across veterinary medicine is unknown. One small research study [4] found that 78% of recent practicing veterinary graduates surveyed reported making mistakes resulting in a potentially adverse outcome for the patient. Most of these errors included failure to perform appropriate diagnostic tests, surgical mistakes during non-neutering procedures, and administration of inappropriate drugs or medical treatment. Each provides avoidable examples if effective levels of written, verbal, and team communication were in place. Although human beings are certainly not infallible, there are several practices and policies that can be taken by veterinary teams to avoid medical errors [5]. Chief among these are fostering a culture that supports open team communication [1, 6]. While not foolproof, such policies and practices should include guidelines for team and client communication when errors do occur that result in harm to patients. Of particular interest in the veterinary error study was the report that 40 percent of the veterinarians had not discussed the error with the client [6]. Certainly clients experience disappointment, loss, and pain when their pet is harmed as a result of the veterinary care received. However, when the veterinarian fails to communicate openly with the client, the disappointment, loss, and pain are often exacerbated and the risk of formal complaint and malpractice is heightened. Barriers to Medical Error Discussions What might have prevented the 40 percent of veterinarians in the study [6] and those in practice from discussing medical error with their clients? These omissions occur despite a veterinary code of ethics [7, 8] that embodies the behaviors of honesty, integrity, and kindness, and mutual respect for opinion and preservation of dignity in interpersonal relationships. Likewise, survey results have consistently declared veterinarians as one of the top three professionals perceived as most honest and ethical [9]. In physician surveys asking if they would discuss medical error with their patients, the majority responded that they believed they would, yet reports consistently show only approximately one-third of physicians disclose [10, 11]. Thus, the difference between what clinicians report they should do compared with what they actually did was striking. Clearly, veterinarians are not alone in their reluctance to engage in these difficult conversations. So what may be contributing to the reluctance to speak the truth when a medical error occurs? To be sure, practitioners in human and in veterinary medicine describe being trained in a culture where excellence is expected and making errors is a source of shame, despite the growing awareness that expecting error-free practice is unrealistic. There is often a fear that revealing errors to clients will result in damage to professional reputation in the community and the profession, possibly setting up the likelihood of the dreaded malpractice claim or state licensing complaint. Some clinicians rationalize that their client has suffered enough due to the medical harm to the pet and nothing could be gained by making him aware of preventable errors that caused the harm. Interestingly, when this has been studied in human medicine, 95 percent of patients and family members said they would want a full and accurate understanding of the causes of any harm experienced as a result of their treatment [12]. They saw the professional s reluctance to disclose as self-serving rather than showing consideration of their feelings. 501
Disclosure: Opening the Door to Discussion Since 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the hospital accrediting body in the United States, has required all accredited hospitals to provide accurate disclosure of adverse medical outcomes to patients [13]. Research in human medicine and other professions [14 16] has described the potential advantages of a more open approach with families and customers in these situations. When applied to veterinary medicine, these benefits include 1. Working together toward reaching resolution without stimulating legal action or formal complaints to licensing boards. 2. Rebuilding client veterinarian trust to resolve disagreements and strengthen relationships. 3. Fair settlement discussions initiated (with guidance from insurance carriers) for those impacted by practice errors. Research has demonstrated these dollar amounts tend to be easier to negotiate and more reasonable than those obtained through legal action [14 17], as client bitterness may be minimized and dollar payments are focused on reasonable compensation and not punishment. Providing full disclosure about medical errors is certainly a complete turnaround to what traditionally has been done in the past. Although full disclosure and even apologizing may appear to be a path to looking to be sued especially in our litigious society, it is now recommended by many lawyers, consultants in risk management, and malpractice insurance companies. Patients in human medicine often sue their physicians in their search for the truth, which they believe was withheld from them and seen as a betrayal of trust. According to the Sorry Works! Coalition [18], which advocates legal protection for doctors who do disclose, we re trying to correct a culture that for 40 or 50 years has told physicians to duck and cover when there s a problem and it s something that we won t turn around overnight. Consider that when clinicians fail to disclose, what often occurs is that the patient ultimately discovers what happened through a medical records review or even through a disgruntled employee. Being forthright and honest could actually be beneficial to the relationship and prevent prolonged negative press and costly litigation. Client Disclosure: A Special Type of Bad News Most veterinarians are very familiar with sharing bad news with clients. Disclosing medical errors to clients requires a similar protocol, although the stakes for the veterinarian and client are very high. These conversations do require delivery of bad news, although the communication challenges are often intensified by strong emotions on the part of clients and veterinary professionals. Such discussions are difficult for numerous reasons, including personal and professional distress, feelings of guilt and shame, fear of potential damage to reputation and business, and especially, fear of a malpractice claim [19]. Adding to the reluctance is the reality that most veterinarians have not been trained or properly versed in conducting such discussions with clients. These situations are characterized as high stakes discussions and call for communication procedural techniques to rebuild trust. These techniques emanate from research on medical error discussions in human medicine and corrective actions in business that focus on addressing the following clientcentered tasks [12, 16, 20]: 1. What happened? 2. How did it happen? 3. What are its consequences? 4. What can be done now? 5. Apologize. 6. How will the mistake be prevented in the future? 7. Offer to discuss restitution/reparation in some form if practice errors caused the harm. Many of the same communication strategies used by veterinarians when sharing bad news with clients are important when disclosing medical error. For instance, veterinarians often set the stage when preparing to deliver bad news [21] by Assuring privacy (seated in private area with minimal distraction); Providing a forewarning: I have sad news to share with you. I m sorry to tell you there s been a serious change in Rusty s condition. ; 502
Speaking slowly; using plain language rather than medicalese; Using active listening and empathy: I can see how difficult this is for you. ; and Providing an opportunity for the client to ask questions: I ve given you a great deal of information at one time. What questions do you have at this point? While all of these elements are applicable in disclosure conversations, a customized protocol using the acronym TEAM has been used [22 23] to guide clinicians in proactively disclosing and resolving medical and systems errors that cause harm. Each component of the TEAM model includes tools and relationship-building strategies to address patient and client needs. T stands for truth and transparency in approaching the conversation. Truth and transparency lead to the client being given an accurate description of the harm and its causes. Would it be okay if I explain what we now believe happened? This depends on teamwork among the veterinary practice team to develop clarity about what happened and following through on all the steps necessary to resolve the matter to the client s satisfaction. E stands for empathizing with the client s experience and communicating your understanding of her thoughts and emotions. I understand you re shocked and angry this was not at all what you were expecting to hear. A stands for offering an apology to the client that takes accountability for the problems in the care that caused harm. It is helpful to distinguish between two types of apology: an apology of sympathy and an apology of responsibility. The apology below is an example of an apology of responsibility. We are so sorry for this error we made that has caused more problems for [Aggie]. An apology of sympathy is I m sorry this happened to you and [Aggie]. After a medical error, the proper type of apology can have a powerful impact on the client or family, making them less angry and suspicious. The apology of responsibility can often lead to an open discussion when it is genuine and coupled with an explanation of the event and an offer of accountability, which are critical steps in rebuilding trust [24]. Accountability includes describing the steps you are taking to reduce the chance of any other animal being similarly harmed. We know from research in human medicine that it is important to patients who have experienced medical errors that something good (such as a reduction in harm to others) come from their experience [17, 25]. We ve already had a team meeting to discuss steps in our procedures to prevent this from happening again to any patients in the future. M stands for the ongoing management of the situation until the most satisfying resolution possible is reached with the client. Management may include providing ongoing clinical care or paying for it at another practice if that is the client s preference. This addresses the client s sense of fairness and reduces perceptions that one has been victimized [16]. Each component of the TEAM model consists of tasks and skills that can be used by the clinician in responding to clients following a medical error. While such discussions are difficult and may still result in formal complaints and possible malpractice suits, research using similar protocols [14] has reduced litigation costs, reduced bitterness and mistrust, and avoided unnecessarily lengthy legal proceeding with the accompanying emotional pain for consumers and clinicians alike. 503
Summary I have provided specific communication principles and tools for high stake discussions with clients following medical error and adverse events. The TEAM framework provides one model based on ethical standards and values of openness as a foundation for discussions with clients about medical errors. Such tools and use of evidence-based models serve to guide veterinarians in restoring client trust and reducing malpractice risk. The author encourages veterinarians to discuss the approach and protocol in your practice for disclosure discussions in the event of medical error. In addition, it is crucial that you consult your malpractice liability insurance carrier to establish its position about how disclosure and resolution should be managed. References 1. Team strategies and tools to enhance performance and patient safety (TeamSTEPPS), 2008, Department of Defense and Agency for Healthcare Research and Quality, http://www.ahrq.gov/qual/teamstepps/. 2. Morey, J. C, R. J. Simon, G. D. Jay, R. L. Wears, M. Salisbury, K. A. Dukes, and S. D. Berns. 2002. Error reduction and performance improvement in the emergency department through formal teamwork training: Evaluation results of the MedTeams Project. Health Services Research 37 (6): 1553 1581. 3. DiMeglio, K., S. Lucas, and C. Padula. 2005. Group cohesion and nurse satisfaction. Journal of Nursing Administration 35 (3): 110 120. 4. Mellanby, R. J., and M. E. Herrtage. 2004. Survey of mistakes made by recent veterinary graduates. Vet Records 155: 761 765. 5. Jenkins, R. H., and A. J. Vaida. 2007. Simple strategies to avoid medication error. American Academy of Family Physicians. Family Practice Management (February). Accessed September 14, 2008 from http://www.aafp.org/fpm/20070200/41simp.html. 6. Myers, W. S. 2008. What to do when you overhear a team member give a client wrong information. Communication Solutions for Veterinarians. Accessed September 14, 2008 from http://www.csvets.com/library/what_to_do_if_team_member_gives_client_wrong_info.pdf. 7. AVMA. 2005. Principles of veterinary medical ethics of the American Veterinary Medical Association (AVMA). In AVMA Membership Directory and Resource Manual. 8. American Association of Equine Practitioners. 2007. Ethical and professional guidelines, Position Statement Protocol. Accessed September 9, 2008 from http://www.aaep.org/images/files/2007epfinal.pdf. 9. Veterinarians rate high on honesty, ethics. 2007. Journal of the American Veterinary Medical Association (February 1). Accessed on September 9l, 2008 from http://www.avma.org/onlnews/javma/feb07/070201o.asp. 10. Gallagher, T. H., A. D. Waterman, A. G. Ebers, et al. 2003. Patients and physicians attitudes regarding disclosure of medical errors. JAMA 289 (8):1001 1007. 11. Lamb, R. M., et al. 2003. Hospital disclosure practices: Result of a national survey. Health Affairs 22 (2): 73 83. 12. Witman A. B., D. M. Park, and S. B. Hardin. 1996. How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Archives of Internal Medicine 156: 2565 2569. 13. Joint Commission on Accreditation of Healthcare Organizations: 2006 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: JCAHO. 14. Kraman, S., and G. Hamm. 1999. Risk management: Extreme honesty may be the best policy. Archives of Internal Medicine 131: 963 967. 15. Boothman, R. 2006. Apologies and a strong defense at the University of Michigan Health System. Physician Executive 32 (7) (March April): 10. 16. Schneider B.,and D. E. Bowen. 1999. Understanding customer delight and outrage. Sloan Management Review 41 (1): 35 45. 17. COPIC Insurance Company: 3 R Program. 2007. COPIC Topics Newsletter (October). Retrieved November 30, 2007, from http://www.callcopic.com/resources/custom/pdf/3rs-newsletter/vol-4-iss-2-oct- 2007.pdf. 18. Redlin, R. 2006. Mistakes happen. Sorry Works! Retrieved September 12, 2008 from http://www.sorryworks.net/media44.phtml. 19. Gallagher, T. H., and M. Lucas. 2005. Should we disclose harmful medical errors to patients? If so, how? Journal of Clinical Outcomes Management 12 (5): 253 259. 20. Blendon, R. J., C. M. DesRoches, M. Brodie, et al. 2002. Views of practicing physicians and the public on medical errors. New England Journal of Medicine 347 (24): 1933 1940. 504
21. Institute for Healthcare Communication. 2007. Module 9, Strangers in crisis: Partners in care. Bayer Animal Health Communication Project, New Haven, CT. http://www.healthcarecomm.org/bahcp/homepage.php. 22. O Connell, D., and S. W. Reifsteck. 2004. Disclosing unexpected outcomes and medical error. Journal of Medical Practice Management 19 (6): 317 323. 23. Institute for Healthcare Communication. 2008. Module 12, Breaking the Silence: Disclosing medical errors. Bayer Animal Health Communication Project, New Haven, CT. http://www.healthcarecomm.org/bahcp/homepage.php. 24. Liebman, C. B., and C. S. Hyman. 2005. Medical error disclosure, mediation skills, and malpractice litigation. Accessed September 15, 2008 from http://medliabilitypa.org/research/liebman0305/liebmanreport.pdf. 25. Vincent, C., M. Young, and A. Phillips. 1994. Why do people sue doctors: A study of patients and relatives taking legal action? Lancet 343:1609 1613. 505